Facility Evaluation Report

At approximately 1:15PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility announced, for the purpose of completing a pre-licensing evaluation. LPA met with Applicant Jotham Gikuhi and toured the facility. The Facility is a 4-bedroom, 2-bathroom, single story home. Fire extinguishers were mounted and charged. Smoke detectors were tested and in working order. There was a carbon monoxide detector present. There was a locked area for medications. There is a secure area for resident records. Beds were made with appropriate linens. There were supplies of additional bedding stored for resident use. 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 infection control posters located throughout the home. Hand sanitizer and/or hand washing locations are throughout the home. A fire clearance for this facility has been granted for 4 Non-Ambulatory residents.

The items listed below need to be corrected before this application will be sent for final approval:

Tools and Toxins in garage need to be secured.

Floor vent in room 4 needs to be replaced.

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

The pre-licensing evaluation has been completed. Applicant will submit self certification of completion of the items listed above. Upon receipt of certification from applicant, 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.