On 08/07/2024, applicant/administrator participated in COMP II. A Pre-licensing facility site inspection / COMP III was requested 09/05/2024. An approved fire clearance was granted to the facility after a fire inspection was conducted on 04/19/2024 and the facility has an approved capacity for Six (6) residents. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The physical plant of the facility consists of a main entrance area, living room, dining room area, garage, six (6) individual resident bedrooms, three (3) resident restrooms, interior storage areas, and kitchen area. The facility has an outdoor area completely fenced in behind the interior physical plant. This outside area for clients can be utilized for outdoor activities/outdoor visitations and has an outdoor patio area with furniture and shade.

The LPA inspected the food service area and observed that knives/sharp instruments are stored in locked drawers inaccessible to clients. All appliances were in operable condition and looked clean/in good repair. Appliances such as microwaves, refrigerators, stoves, etc. are clean and operating properly. Food utensils, dishes, glasses, etc. are clean and in good repair with no cracks or chips. Furniture is room/resident appropriate, clean and in good repair. All rooms are appropriately furnished for their intended use such as bedrooms, dining rooms, kitchens, living rooms, etc. Hot water temperature is maintained between 105-120 degrees Fahrenheit. Outdoor activity spaces have shaded areas and furnished for outdoor use. Each resident has an adult bed with a mattress, pad, bedsprings, and pillow, which are clean and in good repair. Each bed is fitted with sheets, pillowcase, blankets, and bedspread that are clean and in good repair. Each resident has adequate dresser and closet space for clothing and other belongings that includes at least two drawers or adequate dresser space. Continued on 809-C

At the time of the visit, all common areas/interior rooms of the facility were observed to be appropriately furnished, with all furniture in good condition. There are activity materials in the common areas of the facility in good repair and operating condition. The facility maintained a comfortable temperature in all areas inspected. Smoke detectors and carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguishers in all buildings inspected were fully charged and recently purchased in 2024. The LPA observed required postings throughout all common spaces. All window screens were in good repair in all the areas comprising the facility. There is appropriate lighting in all the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, with no changes in incline requiring ramps and/or sturdy hand railings/stair chair accessibility devices. This facility is one (1) story throughout and therefore there are no stairways for clients to utilize. The facility is completely enclosed with a main entrance door and an emergency exit at the rear of the facility. There is a main entrance into the facility on a public street. The facility has walls surrounding the interior of the facility. There are no bodies of water on the facility premises. There is an outdoor activity space for clients equipped with furniture for client use and shade. Continued on 809-C

The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are three (3) resident restrooms in the facility that included soap, paper towels, required postings, and clean trashcans with closed lids. All restrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per the regulations between 105-120 degrees Fahrenheit. There are an adequate number of toilets per client in the facility. Nightlights are installed as observed by LPA. All toilets and hand washing areas are maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences are available accommodate any physically handicapped residents who need such items. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are six (6) designated resident rooms in the facility. Each resident bedroom has a bed/beds, nightstands, and lights and nightstand lamps to provide sufficient lighting. Each closet in all the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any resident assisting device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident. The facility has provisioned to each resident of furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene.

An emergency exiting plan and emergency phone numbers posted in an appropriate place. A current disaster and mass casualty plan maintained at the facility. First-aid supplies, which include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual, are maintained. Administrator’s records, employees and resident records will be maintained at the facility and available for review by the LPA as employees are hired and residents accepted into the facility. The facility will comply with the organization’s standards for health screening, TB clearance, staff training, criminal background clearance and transfer requests. Admission agreements and needs and services (ANS) plan will be maintained for each resident and/or their authorized representative. Contd. 809-C

A Component III Orientation was completed by LPA during this Pre-Licensing Inspection visit to the facility above on 09/17/2024.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when Licensure 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. Copy of this report provided.

Pre-Licensing is complete, and this facility has no deficiencies.