Facility Evaluation Report

Licensing Program Analyst (LPA) Jenifer Tirre visited this facility for the purpose of conducting a Pre-Licensing evaluation. No residents in care during time of visit. Facility is a single story residential home. LPA along with Administrator Khanh Do toured facility.

Fire clearance approval was received on 08/02/21. Structure: Facility is a one story, 6 bedroom (5 resident rooms 1 staff office) 3 bathroom house with an attached garage and a gray exterior. Living Room/ Dining Room : Adequate seating is available in the dining room and living room. Bedrooms Residents: All Residents bedrooms meet Licensing requirements. Bathrooms: All resident bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars and 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 posted on wall. Food Service: Facility has 7 day non-perishables in the pantry. Perishable food to be provided once facility receives residents. Emergency food and water supply on hand. Smoke Detectors: Smoke detectors/ carbon monoxide detector are centrally wired and were tested operational. Fire extinguisher is mounted and charged. Facility has 2 extinguishers. Facility has audible alarms on all sliding/exit doors. Appliances: Stove and refrigerator are operational. Toxins : LPA observed toxins secured in locked garage door. Water Temperature: Tested and recorded at 111.7 degrees F. in facility bathrooms. Reading Material Games, and Equipment:

facility has activities coordinator to do singing and exercises. Medications, First-Aid Kit & Book: Facility has first aid kit with 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 both sides of facility as required. LPA observed shaded outdoor seating.