Facility Evaluation Report

Licensing Program Analyst (LPA) Michael Bilger conducted an announced pre-licensing visit to this facility on 11/26/24 at 10:26am and was met by the Applicant Mary Jane De La Pena . Brief interview was conducted with the Applicant. It was learned through review of the approved fire clearance that this facility will be licensed as an adult residential facility to serve up to 4 non-ambulatory clients. Facility has 4 bedrooms and 2 bathrooms. This Applicant is also seeking vendorization to accept and retain Level 4I clients. There were no clients present during today's pre-licensing visit. Tour of the facility was conducted. Dining area, living area, and all other areas intended for resident use were toured and observed to be furnished and maintained in compliance at this time. LPA observed no obstruction of emergency exits. Exit signs in place as appropriate. Fire extinguishers in place in kitchen area , and fully charged. Facility map indicating emergency exits posted in appropriate locations. Resident rights poster is in place. Kitchen area was toured. Cabinets and drawers were opened and reviewed by this LPA along with the Applicant. Food supply for 2-day perishable and 7-day nonperishable quantities were reviewed to make sure that this facility was in compliance at this time.

Medication cabinet, located in the hallway, was toured and found to be locked. First aid kit was observed to be present and contained all required components at this time. A tour of the resident bedrooms was conducted. Furnishings and furniture intended for use by the clients were observed to be sufficient and able to meet the needs of the clients at this time. A tour of the resident bathrooms was conducted. Hot water temperatures were taken and measured within the range of 105-120 degrees. Linen closet, located in the hallway, was observed to contain a sufficient supply of towels and linens able to meet the needs of the residents at this time. A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, and walkways were observed to be maintained in compliance at this time.

This facility has been found to be in compliance. There were no deficiencies observed during today's Pre-licensing visit. Component III completed with applicant.