Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Administrator/ Licensee Eric Lin. An initial application to operate a Residential Care Facility for the Elderly was received by CCL on 03/04/2022 for a capacity of five non-ambulatory and one bedridden resident. Facility has a covid screening area in the entrance of the facility. LPA observed the PPE supply in the facility.

LPA Lyman along with Licensee/ Administrator toured the facility at 2:08 PM and observed the following:

Structure: Facility is a one story, 6 bedroom, 5 bathroom house with an unattached garage and a white exterior. The exit gates are closed and unlocked. Living Room/ Dining Room : Adequate seating is available in the dining room and living room. Bedrooms Residents: Rooms will be single occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Facility has sanitizer and paper towels in the restrooms. Linens & Hygiene Supplies: Facility has ample bedding and towels for residents in care. Emergency Phone Numbers and Exit Plan: Posted in entrance of facility. Food Service: Facility does not have 2 day perishables and 7 day non-perishables as there are no residents present. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguishers are mounted and charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins / Sharps : Facility has a secured area for toxins and sharps in the garage. Water Temperature: Tested and recorded between 105.4 and 108.3 degrees F. in facility bathrooms. Emergency Supplies: LPA observed emergency food in the facility. Medications, First-Aid Kit & Book: First aid kit observed contained all required items including a first aid guide. Medication is stored and locked in a locked cabinet. Facility to use a medication administration record. Resident & Staff File: Records are stored in a secured file cabinet in the living room. CONTINUED ON LIC 809C DATED 08/24/2022