An application was submitted to Community Care Licensing Department (CCLD) on 08/20/2021 for an initial application to serve Individuals for the ages 18-59 years old, . The requested capacity is for Two (2) non-ambulatory clients, one (1) ambulatory clients, a total capacity of three (3). Structure: The facility is a one-story family home in a residential neighborhood. There is a family room, living room, attached garage, laundry room, 2 common bathrooms, (both of which is wheelchair accessible), kitchen, and backyard. Bedroom Residents: There shall be no more than two clients per bedrooms. Bedrooms #1 are for ambulatory clients, Bedroom #2,3 is for non-ambulatory client. Bedrooms are equipped with one bed, nightstand, chair, lamp, and overhead lightning. Bedroom Staff: No bedrooms are used for live in staff. Bathrooms: Two (2) common bathrooms have a working toilet, showers/bathtub with skid mat, and grab bars. Both bathrooms that will accommodate non-ambulatory clients in a wheelchair. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, fitted sheet, blanket and bedspreads. Ample supply of linen is stored in each bedroom. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers are posted and readily available for review in living room area. Facility is still waiting on a land line telephone. Two (2) fully charged fire extinguishers are located in hall, and and kitchen, serviced on 12/07/21. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils will be stored, and locked away. Ample food supply is stored in the kitchen and consists of the following: 2-day perishables, and 7-day non-perishables.

Medication, First-Aid Kit & Book: Designated centrally stored medication will be locked and located in medication room cabinet. Sufficient bandages, one (1) tweezer, one (1) thermometer, one (1) First Aid Manual, and one (1) pair of scissors. Clients & Staff Files: Designated area for files will be located in locked in garage file cabinet. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance was approved on 11/11/21 does advise of any delayed egress features and/or any locked perimeters. Component III:

Component III was completed at the Pre-Licensing on Friday, 01/28/ 2022 at 11:40 am. Information provided about how to operate the facility within substantial compliance. The following individuals, Jessica, Administrator participated. When the applicant and administrator were asked if they have understood Title 22 they responded in the affirmative.

During the pre-licensing inspection there was one item observed which did not comply with applicable laws and regulations; the following items must be corrected, and proof of correction shall be submitted to the CCLD office to the attention of LPA by 02/11/22. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.

An exit interview was conducted, and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.