Facility Evaluation Report

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a Pre licensing Inspection at the above facility. LPA met Administrator Kelsy Ramos and explained the reason for the visit. Census 6. LPA Lund also did a Component III with Administrator Kelsy Ramos.

LPA Lund and Administrator Kelsy Ramos toured/inspected facility interiors including all common areas to be used by residents. LPA observed that there are four bedrooms immediately available for resident occupation and they contained the required furnishings. Kitchen area was clean and stocked with pots, pans, and dishes. LPA observed sufficient 7- day nonperishable and 2- day perishable food supply. All cleaners were observed inaccessible. Knives and other kitchen hazards will be kept inaccessible. The facility's fireplace is entirely enclosed, and the licensee will add a metal screen as additional secured space between the room and the glass enclosure. Medications will be locked in a cupboard adjacent to the kitchen. Resident files and staff files will be maintained in a neat, orderly and logical manner as to ensure ease of access of information for both facility and Licensing staff. Exterior facility grounds were toured. Facility has a covered patio area for residents. Facility will be licensed for 6 Non-ambulatory including both dementia and hospice wavier for 3. Fire extinguisher are charged and smoke alarms are operating and connected to the whole house alarm system. Facility has required carbon monoxide.

The facility meets the requirements for licensee.