Facility Evaluation Report

On 5/16/2023, Licensing Program Analyst (LPA) Evelin Rios conducted an announced Pre-Licensing visit to the facility mentioned above. LPA met with applicant Liana Avanesyan. The purpose of today’s visit was explained. This is an initial application for an RCFE. A fire clearance dated 12/16/2022 was received for five (5) non-ambulatory residents and one (1) bedridden resident.

At 9:45 a.m. LPA and applicant toured the physical plant inside and out. LPA observed the following:

Living Room : The living room is furnished with comfortable seating and a television.

Kitch en: T he facility has one fire extinguisher located on a wall by the kitchen that was observed fully charged with purchased date of 4/27/2023. There are two functioning telephones on the premises, one by the kitchen and the other by the dining table. Knives were locked in a kitchen drawer. Centrally stored medications will be locked in a kitchen cabinet. First aide kit was locked in the same cabinet. The pantry contained a seven-day supply of non-perishable foods and the refrigerator contained a 2-day supply of non-perishable foods. LPA observed the facility menu posted on the kitchen refrigerator. LPA observed enough plates, cups and silverware for the capacity of the facility. A stacked washer and dryer are located in the kitchen and observed to be operational. Laundry detergent and cleaning products are kept locked in the garage and will be inaccessible to residents. The facility PPE is stored in a kitchen drawer.

Dining Area: LPA observed a dining table with chairs able to seat the capacity of the facility. Resident and staff records will be kept in a locked cabinet in the dining area. A screened fire place was observed and is not in use.

Hallway Closets : Hallway closets contained extra clean linens and bathroom supplies. LPA observed board games and activities for residents. The emergency exit plan/sketch is posted on the walls throughout the facility. (LIC809-C continued on to next page)