Pre-licensing visit·February 3, 2023

Licensing Program Analyst (LPA), Martha Arroyo conducted a pre-licensing visit to this property at 9:00am on 02/03/2023 and met with Applicant Representative Kevin Fitzgerald. The applicant has obtained fire clearance for a total capacity of five (5) non-ambulatory residents, and one (1) bedridden resident in bedroom #5 for a total capacity of six (6) residents. LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. At 9:11am, all hard-wired smoke alarms and carbon monoxide detectors were tested and function properly. LPA observed one (1) fire extinguisher to be new and fully charged. There are four (4) single occupancy bedrooms and one (1) double occupancy bedrooms for resident use. There will be no-live in staff. Facility will have 24-hour wake staff. Each bedroom is equipped with clean mattresses, pillows, and bedding. There is sufficient supply of linens, including blankets, bath towels and wash cloths. Bedrooms have sufficient lighting. The facility has two (2) bathroom for resident use. Resident bathrooms contained appropriate non-skid mats and grab bars. Bathrooms have sufficient paper products. Night-lights were present in the main hallway. Hot water measured in each bathroom; first bathroom measured at 111.2 degrees Fahrenheit at 9:07am, and second bathroom measured at 109.4 degrees Fahrenheit at 9:10am. LPA toured the kitchen area at 9:13am. The facility has at least seven (7) day supply of non-perishable food. Appliances and all equipment appear to be clean and in good repair. Kitchen knives are stored in a locked cabinet next to the pantry. The kitchen has a sufficient supply of plates, cups, cook ware and utensils. The living areas and dining areas are clean and properly furnished. All window screens and coverings are in good repair. Enough seating for six (6) residents at the same time in the dining room table. A working telephone is present. There are activity supplies for future residents. Report Continued on LIC 809C... Report Continued from LIC 809... Medications will be stored and locked in the laundry room. First aid kit was observed to have bandages, thermometer, scissors, tweezers and a current first aid manual. Facility records will be stored and locked in a file cabinet by the kitchen. Garage: The garage is attached to the house and will be locked at all times. Detergents, disinfectants, and cleaning supplies are stored and inaccessible. There will be no firearms/ammunition stored on the property. The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights. Facility will have one central entry point designated for universal screening. Alcohol-based hand sanitizer and masks available upon entry. Facility has an adequate 30-day supply of Personal Protection Equipment (PPE). The exterior passageways were clean and clear of any obstructions. There is one (1) self-latching gate for emergency use. There are no bodies of water on the premises at the time of the visit . LPA observed the backyard, which has a covered outdoor area for resident use. Physical plant is consistent with the submitted facility sketch/floor plan. The physical plant of this facility location is in compliance with Title 22 regulations at this time. Comp III conducted with Applicant Representative. 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 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. A copy of the report was reviewed and provided to Applicant Representative Kevin Fitzgerald.