Pre-licensing visit·August 6, 2024

Licensing Program Analysts (LPAs), Martha Arroyo and Erica Mosley conducted a pre-licensing visit to this property at 9:30 a.m. LPAs met with Applicant Representative Sara Jackson as this is a change of ownership application from Sally’s Residential Care Home, Inc. #565800706 to Sally Residential Care Home 3 #565850406. The applicant has obtained fire clearance for a total capacity of six (6) residents, all of which may be bedridden in bedrooms #1 - #4. The facility has a dementia program in place. LPAs inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The hard-wired smoke alarms and carbon monoxide detectors were tested and function properly. LPAs observed one (1) fire extinguisher to be new and fully charged on 08/04/2024. There is one (1) double occupancy bedroom and four (4) single occupancy bedrooms for resident use and one (1) staff room. Each bedroom is equipped with clean mattresses, pillows, and bedding. Bedrooms have sufficient lighting. There is a cabinet in the hallway with a sufficient supply of linens, including blankets, bath towels and wash cloths. There is a locked closet with the resident’s personal hygiene items. The facility has two (2) bathrooms for resident use. Resident bathrooms contained appropriate non-skid mats and grab bars. Bathrooms have sufficient paper products. Hot water temperature was measured in both bathrooms, and they measured between 105- and 120-degrees Fahrenheit. LPAs observed trash cans with tight fitting lids at the time of the visit. LPAs toured the kitchen area at 9:40 a.m. The facility has at least seven (7) day supply of non-perishable food and two (2) days perishable food. Report Continued on LIC 809C... Report Continued from LIC 809... Appliances and all equipment appear to be clean and in good repair. Kitchen knives and sharps were observed in a locked drawer next to the gas range. The kitchen has a sufficient supply of plates, cups, cookware, 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 in the living room. Night-lights were present in the common areas. All doors have functioning auditory alarms when opened. Medications are stored and locked in a file cabinet adjacent to the dining room. Facility records and First aid kit was by the medications. First aid kit was observed to have bandages, thermometer, scissors, tweezers and a current first aid manual. Facility has an adequate 30-day supply of Personal Protection Equipment (PPE). The garage is attached to the house and inaccessible to residents in care. The washer and dryer was observed inside the garage. Detergents, disinfectants, and cleaning supplies are stored locked and inaccessible. There will be no firearms/ammunition stored on the property. There is a sufficient supply of emergency food and water. The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights. 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 . LPAs observed the backyard, which has a covered outdoor area with a table and chairs for resident use. Comp III conducted with Applicant Representative. Report Continued on LIC 809C... Report Continued from LIC 809C... Physical plant is NOT accurate with the submitted facility sketch / floor plan. The following needs to be completed prior to licensure: · Submit a new facility sketch / floor plan and obtain fire clearance for additional rooms. 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. The report was reviewed, and a copy was provided.