Pre-licensing visit·November 4, 2022

Licensing Program Analyst (LPA) KaSandra Lopez conducted a pre-licensing visit to the above noted facility. The LPA met with applicants Helen Rose Busch and Johnna Udden. This is a new facility. A dementia program was included in the plan of operation. A Hospice Waiver for six has been requested. Component III was conducted with the applicants after the physical plant tour of the facility. The facility is a single story home. At 9:15 AM, a physical plant tour was conducted inside and out. The is a table at the entry of the facility for screening of visitors. An approved fire clearance was received, clearing them for five (5) non-ambulatory residents and one (1) bedridden residents in bedroom #5. The facility has one (1) private resident bedrooms (bedroom #2), three (3) shared bedrooms (bedrooms #1, #5, & #6), one (1) staff bedroom (bedroom # 4), and one (1) extra bedroom (bedroom #3) which can be used as an isolation room. Two bedrooms have direct exits outside. All resident rooms were furnished appropriately, although bedroom #1 is lacking closet space. The beds are furnished with a comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. All rooms were free of odors. All window screens were clean and maintained in good repair. There is one bathroom in the hallway and two private bathrooms in bedroom #5 and bedroom #6. The resident bathrooms have a showers with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms measured at 110 degrees F. Resident and staff records are stored in a locked cabinet which is currently located in the kitchen/dining area. Medications are centrally stored in a locked cabinet in the kitchen/dining area also. The first aid supplies were complete, including a thermometer and a current version of a first aid manual and currently stored in the garage. Report continued on LIC 809-C. Kitchen knives are stored in a locked drawer in the kitchen. Stove burners are currently accessible to the residents. The applicant stated they will purchase safety covers for the knobs. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry, and house cleaning supplies are stored in a locked cabinet located in the kitchen and garage. No flies or other vermin were observed. The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and/or activity supplies in the living room and dining area . There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to non-private bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely . There is a fireplace in the living room. It is screened and there are no tools present. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit. There is no central air but facility has a portable fans for cooling. The facility smoke alarm system is hard wired. There is a pull station at the front entry of the house. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There one fire extinguisher fully charged and purchased on 10/01/2022. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) and extra incontinence supplies were adequate and are stored in garage. There is a functioning telephone on the premises. The emergency exiting plans/sketch, emergency telephone numbers, and other required postings are posted in the entry of the home. The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs where residents can sit. The entire backyard property is fenced. Continued on LIC 809-C. The back and sides of the house are separated from the front yard by gates. The two backyard gates currently are not self-latching. There is no locked storage in the backyard although the applicant stated they will be purchasing one to secure gardening tools. There are no bodies of water on the premises at the present time. The garage is accessible from inside the house. Items that can pose a danger to residents will be secured in locked storage. Currently, the only way to access the backyard from inside the home is through resident bedroom #5 or bedroom #6. There is no common room with direct access to the backyard. The attached garage also does not have direct access to the backyard and the only access would be from the front door or through the garage door leading to the front of the home. It was discussed with the applicant the possibility of changing bedroom #6 to a common activity room and changing bedroom #3 from an isolation room to a permanent resident bedroom. The LPA stated they would discuss the situation with management and get back to the applicant. The following items must be corrected prior to licensure. 1. Clarification on the issue of direct access to the backyard; and updated facility sketch possibly. 2. Closet space for two residents in bedroom #1. 3. Safety modification for the stove 4. Proof of self latching gates in the backyard. Submit proof of corrections to LPA Lopez. This report will be sent to the Centralized Application Bureau (CAB) once all corrections are received. You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.