Pre-licensing visit·October 12, 2023

Licensing Program Analyst (LPA) Sandra Urena conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Erna Vanoyan. This is an application for a new facility. The facility applied for five (5) non-ambulatory residents, and one (1) bedridden resident. At 10:15 a.m., the LPA and the applicant conducted a physical plant tour inside and out to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is a one-story dwelling. An approved fire clearance was received on 08/08/2023, clearing them for five (5) non-ambulatory residents; one (1) bedridden resident in bedroom #1. KITCHEN: Kitchen knives are stored in a locked kitchen drawer. The supply of dishes, utensils, pots, pans, and drinkware is adequate. The temperatures for the refrigerator and freezer were observed to be withing the approved temperatures. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, and house cleaning supplies are stored and locked under the sink cabinet area. No flies or other vermin were observed. Water temperature was recorded at 112.3 degrees Fahrenheit. BEDROOMS: The facility has two (2) private residents’ bedrooms: rooms 1 and room 3; and two (2) shared room(s), room 2 and room 4. One residents’ bedroom, room # 2 has a direct exit to the patio. Bedroom # 1 has been approved and cleared for one bedridden resident. All bedrooms were set up with night stands, lamps, and closet space. Continues on LIC 809C... Page 2. All beds were furnished with box springs, comfortable mattress and clean linen, which includes, a mattress pad, top and bottom linens, pillowcases, and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath, or toilet. There are no staff rooms – ‘awake night staff only’ - is required. All rooms were free of odors. All window screens were clean and maintained in good repair. BATHROOMS: There are two (2) bathrooms #1 and #2, one is in the hallway between rooms #2 and #3. One bathroom is in room #4. Bathrooms have non-skid mats. The toilets need to have grab bars. Hot water temperature was tested and recorded at 112.1 degrees in bathroom #1 and #2 and was recorded at 107.9 degrees Fahrenheit. COMMON AREAS: The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and/or activity supplies in the living room and dining area There was sufficient space to accommodate both indoor and outdoor activities. Night lights were observed in hallways and passageways to non-private bathrooms. There is a fireplace in the living room, which is covered with a fire safe cover. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has central heating system, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit. Page 3. The facility smoke alarm system is hard wired. The smoke detectors were tested and functioned properly during the time of visit. There is one (1) fire extinguisher mounted on the wall between the kitchen and the dining room. The extinguisher did not have a purchase date receipt, consequently the LPA was unable to verify functionality. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted on the wall by the main entrance, as well as other required postings are posted in the main common area. Resident and staff records are stored in a filing cabinet, which is currently located in the common room area. Medications are centrally stored in a locked bottom kitchen cabinet. The first aid supplies were complete. The laundry area is located next to the kitchen. Washer and dryer appeared to be functional. Laundry detergents are stored in a locked cabinet next to the washer and dryer The supply of extra bed and bath linens is adequate and is located in the linen closets found in the hallway between room #2 and room #3. Personal hygiene items (shampoos, soaps) were adequate. OUTDOOR AREA: The exterior passageways were clean and clear of any obstructions. There is a covered patio and patio furniture. The entire property is fenced. The back and sides of the house are separated from the front yard by gates at the north and south side passageways. A separate structure is located behind the facility and separated by a fence. The structure is the living residence of the applicant. The garage is inaccessible from the house; the door will be maintained locked. At 12:30 p.m., the applicant completed Component III Orientation. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview was conducted and reviewed with applicant Erna Vanoyan. A copy of the report was issued.