Facility Evaluation Report

Licensing Program Analyst's (LPA's) Jenifer Tirre and Michael Tea visited this facility for the purpose of conducting a Pre-Licensing evaluation for change of location. Facility is a single story residential home. LPA's along with Licensee/Administrator Tin Le toured facility at 2:10 PM and observed the following:

Fire clearance approval was received on 03/14/24. Structure: Facility is a one story, 4 bedroom (3 Residents bedrooms and 1 live in staff bedroom) 2 bathroom house with attached garage and a white exterior. Living Room/ Dining Room : Adequate seating is available in the dining room and living room. Bedrooms Residents: All Residents bedrooms need additional furnishings such as beds. Bathrooms: All resident bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars. One of two restrooms has a non-skid surface in the shower. Linens & Hygiene Supplies: Facility has adequate supply of linens and towels. Emergency Phone Numbers and Exit Plan: Facility has Emergency Plan. Food Service: Facility does not have 2 day perishables & 7 day non-perishables in the pantry/ refrigerator, as well as emergency food and water supply. Smoke Detectors: Smoke detectors/ carbon monoxide detector are centrally wired and were tested operational. Facility has one fire extinguisher which is mounted and charged. Facility has audible alarms on entry/exit doors. Appliances: Gas Stove and refrigerator are operational. Toxins : LPA observed toxins secured in storage area.. Water Temperature: Tested and recorded at 106.7 degrees F. in facility bathrooms. Reading Material Games, and Equipment:

facility did not have activity supplies at time of visit. Medications, First-Aid Kit & Book: Facility did not have first aid kit or First aid manual present at the facility. Facility has a secured location for medications and facility files. Backyard: LPA observed the facility perimeter is secured by wall with a self latching gate on right side of facility as required. LPA observed shaded outdoor seating.

Component III Orientation was waived during this pre-licensing visit due to Administrator presently operating several facilities.