Facility Evaluation Report

At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility for the purpose of completing a pre-licensing evaluation. LPA met with Applicant and toured the facility. The Facility is a 5-bedroom, 3-bathroom, single story house. Fire extinguishers were mounted and charged. The fire system was being tested during this visit. Carbon monoxide detector was present. There was a locked area for medications, files and several for toxins and cleaning supplies. Beds were made with appropriate linens. 4 of 5 Client rooms contained the required furniture. Hot water temperature was tested and found to be within regulation between 105 degrees F and 120 degrees F at faucets accessible to residents.

Approval of this application is pending completion of the following:

Applicant will submit photos of completed items to LPA upon completion.

Upon receipt of all items, this application will be forward for final review and approval by Licensing Program Manager.

Component III orientation was completed during this visit.