Facility Evaluation Report

Licensing Program Analyst (LPA) Gary Tan conducted an announced Pre licensing visit at this facility and met with Licensee Representative Dr. Sharouz Ghodsian and explained the reason for the visit. At approximately 9:52 AM, LPA toured the facility with the Licensee representative inside and out.

The facility is a two-storey building with nine (9) bedrooms and nine (9) bathrooms, pantry, activities areas/common rooms on both floors, lactation room, staff offices, medication room and outdoor areas. It has an approved fire clearance for fourteen (14) clients and two (2) non-ambulatory clients on Room #3 and Room #4. The facility uses surveillance cameras in the common areas inside.

There is a screening station upon entry which contained a hand sanitizer, gloves, mask and a visitor log. Postings included grievance procedures, personal rights, confidential complaint contacts, house rules. Will also post activity schedule and facility menu. Walls, floors, ceilings, windows, and blinds were clean and in good repair. At approximately 10:35 AM. LPA reviewed the last smoke alarm test done at the facility on 02/22/24. LPA measured the room temperature to be at 74°F. At 11:05 AM. LPA tested the carbon monoxide detector to be operational. Hot water temperature was set at 118°F in the boiler room. LPA measured the water in a hallway bathroom to be at 114.2°F. Past the reception and screening station were an intake office and a mud room. The mud room contained a laundry and dryer machines, toilet and shower and will have Zapp machine for sanitation and bed bug prevention. Janitor closets with cleaning supplies on the first and second floor were locked. Extra linens, client lockers, activities, board games, and hygiene supplies were located in storage closets on the first and second floor. The facility has emergency water supplies and emergency food supplies in the first-floor pantry. The pantry contained sufficient supplies of non-perishable only food at this time. The pantry also contained refrigerators, freezers, cooking tops and a retherm unit. Sharps will be locked in a cabinet by the sink in the pantry. The dining room outside of the pantry contained utensils, coffee machine and snacks.