Facility Evaluation Report

Licensing Program Analyst (LPA) Bethany Mirlohi arrived announced to conduct a pre-licensing inspection. LPA met with Administrators Estelita Cailing and Adam Dickey during today's inspection. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks. In addition, staff screened LPA upon entrance.

Facility was inspected both indoors and outdoors. LPA inspected 5 resident bedrooms, 2 staff room, 3 bathrooms, common living areas, and kitchen. Outdoor area is free from hazardous debris. Outdoor exits are clear and accessible. There is an outdoor shed located on the side of the house used as storage. First aid kit was present in the facility. Centrally stored medications will be locked in the laundry room cabinet. The facility has adequate lighting throughout and night lights in the hallways. LPA inspected resident bedrooms and the bedroom had appropriate furnishings, chair, adequate lighting and storage. Bathrooms are clean, sanitary, and in good repair. LPA observed grab bars and non-skid mats present in the bathrooms. Smoke detectors and carbon monoxide detectors were checked and operational. Fire clearance was granted on 11/01/21 for 1 non-ambulatory and 4 ambulatory residents. Kitchen is clean, sanitary, and in good repair. A working telephone has been set up for resident use.

Competent III was completed during today's inspection with licensee. Licensee is required to contact Community Care Licensing upon the admittance of their first consumer, after licensure. This report will be forwarded to the centralized application unit for continued processing.