Pre-licensing visit·June 9, 2021

Licensing Program Analyst (LPA) Kelly Dulek conducted a pre-licensing inspection for this proposed facility on 6/9/2021 at 9:20AM. This is a change of ownership application. Becky Spring will be the Administrator for the proposed facility and was present during today’s visit. Also present during today’s visit were licensee representatives Jason Meek and Rena Sepulveda, as well as Hickory House licensees Angely and Paul Morales. A tour of the facility was initiated at 9:22AM with the Administrator and Angely Morales. LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. The following was noted: The facility consists of 21 (twenty one) total bedrooms – 17 (seventeen) shared rooms and 4 (four) private rooms as well as 9 (nine) total bathrooms, 8 (eight) of which are designated for client use and 1 (one) for staff use. Shared facility space includes a common sitting room and dining area. There is currently a total of 36 (thirty six) residents residing at the facility. Fire clearance was approved on 12/2/2020 for 36 Ambulatory only residents. LPA informed Administrator and licensee representatives that the current facility is approved for 36 total residents, 8 of which are non-Ambulatory. Licensee representatives will submit to CCL a new LIC 9054 and LIC 200, indicating a request for 8 non-Ambulatory residents. Fire extinguishers were last serviced on 8/20/2020. Fire alarms/carbon monoxide detectors were checked during the fire inspection on 12/2/2020. LPA observed all required postings on the wall in the main hallway/entryway. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Report Continued on LIC809-C Cleaning supplies are stored in a locked cabinet. Knives and sharp objects are stored locked. Medication: Medication room was observed locked and contained all resident medications and active resident files. First aid supplies are available. Bedrooms: There are 21 total bedrooms in the facility. 4 are private resident bedrooms and 17 are shared resident bedrooms. All client bedrooms were checked and were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens. Bathrooms: LPA observed all 8 resident bathrooms were clean, properly supplied and had functional fixtures. LPA observed all bathrooms to have grab bars and non-skid mats. Residents have sufficient amounts of supplies for personal hygiene, which are stored locked. LPA checked water temperature in various bathrooms during the visit, all measured within regulation of 105-120 degrees F. Common Areas : These included the common seating area and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a designated telephone available for resident use. Surrounding Grounds (Outdoors) : There were 2 shaded areas with proper furniture for outdoor use. There are no bodies of water on the premises. In addition, during the visit for another of the licensee’s facilities on 6/8/2021, LPA JoAnn Rosales completed Component III with the licensee representatives and Administrator. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating under the new license until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted with Administrator. A copy of report was provided via email.