Facility Evaluation Report

Licensing Program Analyst (LPA) Ruth Wallace conducted announced pre-licensing visit. LPA Wallace discussed the purpose of the visit and the elements of the pre-licensing visit with licensee.

Facility has a fire clearance for 2 non-ambulatory and 4 ambulatory clients. Licensee will be the Administrator of this facility. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. The facility was toured both indoor and outdoors with licensee.      .

The facility bedrooms are furnished with all required furniture. The facility bathrooms are furnished and sanitary. The living room, dinning room, and common areas are furnished. The facility has a public telephone. The facility has a fire extinguisher and expires on 8/11/2023 . The facility has smoke detectors and carbon monoxide detectors. The facility water temperature was 110.5 degrees. The exterior of the facility is free of debris and has patio furniture. The facility has the required food supply, and has a emergency water and food kit. The facility has all required facility files and postings. The facility has a locked cabinet for medications. The facility has a medication binder for clients, and have personal medication storage boxes for residents. The facility has a first aid kit and a flash light.

The applicant has passed the pre-licensing component of the application process. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed. Component 3 was completed with LPA Wallace. An exit interview was conducted with licensee and a copy of this report was provided at facility.