Facility Evaluation Report

Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Dante Ward, Licensee and Administrator. LPA toured the facility, all exits were unobstructed, and observed a COVID-19 screening station. Fire extinguisher was charged and serviced 02/22/2023. The facility has a supply of PPE. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms. There are 6 smoke detectors & 1 carbon monoxide detector, which were tested & observed operational.

Due to time constraint, LPA will return at a later date to complete the inspection tool kit and issue citations if warranted.

LPA requested the following updated forms to be submitted to Community Care Licensing by 04/07/2023:

· LIC 308 Designation of Facility Responsibility (1 person per form)

· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)

· LIC 9020 Register of Facility Residents

· Copy of current Administrator's Certificate

· Copy of current Lease/Rental Agreement or Property Tax document showing control of property.

Exit interview conducted with Administrator, whose signature on this document confirms receipt. No deficiencies cited.