The licensee has applied for a license to serve (6) elderly residents ages 59 and older. The fire clearance is approved for (6) ambulatory only residents.

A tour was conducted of the kitchen, dining room, living room, (5) bedrooms, and (2) bathrooms.

The following was observed during this visit:

MEDICATIONS

There is a locked centralized storage area for Resident medications in facility kitchen.

PHYSICAL PLANT

Facility is clean, sanitary and in good repair. Protective devices are in place. Indoor and outdoor passageways, stairways, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68°F. degrees and 73°F. degrees. Open porches and areas of potential hazard are well-lit. Seven interconnected and hardwired smoke alarms were tested and operate properly.

Continued on 809-C

There is a bed for each client with a mattress, mattress pad, bedsprings, and pillow(s) which are clean and in good repair.

Mattresses and pillows are flame-retardant. There is dresser and closet space for each client that includes at least two (2) drawers or eight (8) cubic feet of dresser space per client. There is a chair for each client and at least one (1) nightstand per two (2) clients.

BATHROOMS

There are two (2) toilets and washbasin per six (6) clients, family, and personnel. There are (2) shower or bathtub per ten (10) clients, family, and personnel. The hot water temperature measured at 111° Fahrenheit. The bathrooms are located near the client’s bedrooms.

SUPPLIES

There are clients’ personal hygiene supplies to include soap, toothpaste, toilet paper. There is a sufficient supply of clean linens to permit weekly changing or more of top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths.

FOOD SERVICE

Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer and refrigerator are the appropriate temperature. A seven (7) day supply of non-perishable food is present. There is enough tableware, tables, dishes, and utensils. There is enough equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean.

RECORDS

There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility.

Continued on 809-C

There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to clients for visitors.

MISCELLANEOUS

There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries.

During this pre-licensing inspection, LPA did not find corrections are needed. LPA conducted the Component III Orientation with the Licensee and copy of this report was provided. A copy of the facility evaluation report will be available to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with their assigned CAU Analyst.

Exit interview conducted with Najma Shaheen/Administrator-Licensee.