Facility Evaluation Report

Licensing Program Analyst (LPA) Jill Nakagawa conducted an initial pre-licensing inspection and met with Simeon Boyd, the Licensee. The facility has a fire clearance approval from the Davis Fire Department of 5 nonambulatory, and 1 bedridden, for a total capacity of 6 residents. The facility has a Dementia Care Plan within their Plan of Operation. Facility will operate with hourly staff and Licensee will ensure sufficient staffing at all times.

During today’s visit LPA observed the following items:

· COVID-19 screening station with visitor log.

· Lockable separate cabinets for medications, toxins/cleaners, and knives.

· 10 hardwired smoke detectors, which were tested and observed operational.

· 2 carbon monoxide detectors, tested and observed operational.

· Complete First Aid kit, night-lights, and flashlights for emergency lighting.

Component III orientation was completed with the applicant during this inspection.