Facility Evaluation Report

At approximately 8:10AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility for the purpose of completing a pre-licensing evaluation. LPA met with Applicant David Gilbert and toured the facility. The Facility is a 8-bedroom, 3-bathroom, single story house. Fire extinguishers were mounted and charged. Smoke detectors were tested and in working order. Carbon monoxide detector was present and operational. There was a locked area for medications and several for toxins and cleaning supplies. Beds were made with appropriate linens. Resident rooms contained furniture as required in all rooms. Hot water temperature was tested and found to be within regulation between 105 degrees F and 120 degrees F at faucets accessible to residents. Facility has two offices with secure storage for files.

A fire clearance for this facility has been granted for 14 ambulatory and 2 non-ambulatory residents.

Component III orientation was conducted at facility. Applicant conveyed a good knowledge of Title 22 regulations.

The pre-licensing evaluation has been completed. LPA will submit the application packet for a final review and approval from the Licensing Program Manager.

This report was reviewed with applicant and a copy was provided.