Pre-licensing visit·August 9, 2022

Licensing Program Analyst (LPA) Delmundo conducted an announced pre-licensing inspection. License application is for six (6) total capacity, all non-ambulatory. Fire clearance was granted on July 4, 2022. LPA met with Emelita Dimaguila & Harold Dimaguila, applicants. LPA toured the facility inside out. There is no body of water. LPA inspected the living room, dining area, kitchen, bedrooms, bathrooms, side and backyard. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Central storage for medications was observed with lock. Complaint and Ombudsman posters, Residents Personal Rights and Rights to Resident Council were posted in the prominent place. Bathrooms/showers were observed equipped with grab bars and non-skid mats. A central screening area for staff and visitors was observed set-up close to the entrance door with Visitor's Log. COVID-19 signages were observed all through out the facility. Facility's Infection Control Plan was requested by LPA and received on August 2, 2022. Fire extinguishers were observed fully charge and when verified, Emelita stated the units were purchased last year. LPA discussed the units to be serviced every year. Carbon monoxide and smoke detectors were tested and observed operational. First aid kit is complete with manual. Facility has flash lights for emergency lighting. Hot water temperature in one of the bathrooms was tested and measured at 115.4 degrees Fahrenheit. ....continued on 809C (page 2) Page 2 LPA observed the following: 1. Physical plant is not consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. Ensuite bathroom in the back bedroom not indicated in the sketch . This bedroom indicated shared by three residents; however, per Title 22 Regulations 87307(a)(2)(D), not more than two residents shall sleep in a bedroom. 2. Kitchen cabinet where sharps are kept has no lock. 3. Storage in the back yard no lock. 4. No auditory signals on entrance and exit doors. 5. There''s only one call button/bell for residents' use. 6. Stove knobs no cover. 7. Trash bins' lids in the bathrooms and bedrooms are not touch free. 8. Pieces of wood and metal grill, collapsed head board and boxes in the front yard. Pieces of tiles and bags of cement in the backyard 9. Uneven cemented backyard surface. 10. Theft and Loss Policy and Rights to Family Council not posted. 11. N95 respirators and disposable gowns not sufficient for 30 days. Applicants to submit the following proof of corrections (POCs) by August 23, 2022: Picture showing lock is installed on kitchen cabinet where sharps are kept. Picture showing storage in the backyard is locked. Picture showing auditory signals installed. Proof of purchase for call buttons/bells, stove knob covers, trash bins with foot pedal operated lids,. disposable gowns and N95 respirators. Pictures showing front and back yard cleaned. Picture showing backyard surface leveled. Pictures showing facility's Theft & Loss Policy and Right to Family Council posted. .....continued next page (page 3) Page 3 Updated sketches showing the following: -Dimensions and use of each room (e.g. staff bedroom, residents bedroom, toilet/bathroom) -Number of resident(s)in each bedroom -Utility shut off locations -Exit doors and windows -Outside sketch showing the building, driveway, perimeter fence and storage in the backyard LIC200 Application for 5 total capacity Harold Dimaguila stated he's been fit tested for N95 respirator and Emelita Dimaguila and other 2 staff are still yet to be tested . Applicants stated they will purchase N95 Qualitative Fit Testing kit and have all staff fit tested. LPA informed to have copies of proof to be submitted upon admission of first resident. Upon receipt of LIC200 and updated sketches, LPA will submit to Central Application Bureau (CAB) analyst who in turn will submit a new request for fire safety inspection. LPA will inform CAB analyst when POCS for the other deficiencies are received. LPA reminded applicant to obtain $3M liability insurance upon admission of first resident and submit copy to LPA. LPA also reminded to have antigen test kits available. Final review of application and license to be granted by CAB analyst. Exit interview conducted and copy of this report provided.