Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced for the purpose of reviewing the physical plant for capacity increase requested from five to six residents. LPA were greeted by caregiver Gilbert Shivachi . Licensee, Emma Mutunga, was not able to come to the facility, but was available over the phone and gave authorization for caregiver to sign the report.

Previously on 6/2/26, LPA toured the facility and observed two fire doors installed involved in the capacity increase per fire department request.

During today's visit, LPA had a conversation with Licensee to explain them that the updated fire clearance dated 6/15/26 indicates that the capacity increase was not approved. Licensee is expecting to get approved for capacity increase from five to six residents and made changes requested by the fire department to obtain their approval for their fire clearance reflecting the capacity increase. LPA observed that the two fire doors remained closed during LPA's visit, which it represent a concern about residents needing assistance with their care needs because doors prevent staff to get alerted if they remained closed at all times. LPA explained the concern to the Licensee, who stated that the doors have door stops to prevent them from closing, staff immediately placed door stops and open both doors. Licensee expressed that they will contact the fire department to request approval of capacity increase from five to six residents.

No deficiencies found at the time of visit. Exit interview conducted with staff and copy of this report was given.