Facility Evaluation Report

Licensing Program Analyst (LPA) Elizabeth Irra conducted an announced pre-licensing visit. LPA met with Leilani Libang (Applicant) and Ray Libang. On 03/24/24, the Fire Department granted fire clearance for (5) bedridden clients. This facility is to operate as an Adult Residential Facility for Persons with Special Healthcare Needs (ARFPSHN). There are currently (3) clients residing at this home under the current licensee Andover Home (198601826). Divine Villa (198603738) will be taking over the operation of this home. Note: Per Applicant, the current licensee will be taking all furnishing and applicant will be replacing all items including all utilities once licensure has been granted. Component III was also completed during this visit.

This is a single-story home which consists of (5) bedrooms fully equipped with mechanical lifts, (3) bathrooms of which one (1) is equipped with a mechanical lift, reclining shower chair, shower trolley in client bathroom (located near bedroom #5), living room, kitchen, dining room, laundry room/office, backyard shaded patio area, and attached garage.

Building and grounds are free from hazards.

Fire extinguishers (service date: 12/28/23) (1) is located in the hallway and the other near the kitchen.

Cleaning solutions (under kitchen sink) and sharps are locked in the kitchen.

Pantry's cupboards, freezers, stoves, microwaves, refrigerator and counters are clean.

Two-day supply of perishables available, seven-day supply of non-perishable available.

**Refer to LIC 809C for the continuation of this report**