Facility Evaluation Report

Licensing Program Analyst (LPA), Natasha Persaud conducted an announced Pre-Licensing/Component III inspection. LPA identified herself and explained the purpose of the visit with Applicant/Licensee, Rowena Khadiri to ensure Title 22 compliance. An initial application was received by the Department on 12/17/2020. The Applicant/Licensee requested to be licensed for a capacity of four (4) Ambulatory Developmentally Disabled adults, ages 18-59.

Structure - The facility is a one story structure with 3 bedrooms, and 2 bathrooms. There is an outdoor covered area for client use. No bodies of water were observed. Per the Applicant, there are no firearms or weapons on the premises.

B edrooms Residents - Rooms #1, #2, and #3 will be used for Ambulatory clients only.

Bedrooms Staff - There are no staff rooms.

Bathrooms - All bathrooms have a working toilet, sink, and non-skid rugs.

Linens & Hygiene Supplies - Adequate supply.

Emergency Phone Numbers, Exit Plan and Required Postings - Posted.

Smoke Detectors and Carbon Monoxide Detectors- Operational.

Appliances - Stove burners, oven, microwave, washer, and dryer working.

Water Temperature - Measured at 120 degrees F.

Medications- Centrally stored and locked in a closet.

First-Aid Kit - Stored in a locked closet.

Resident & Staff Files - Located in a locked closet.

Component III - Conducted at the Pre-Licensing visit. Information provided about how to operate the facility within substantial compliance.