Pre-licensing visit·December 7, 2023

At 10:08 am Licensing Program Analyst (LPA) Tihesha Smith conducted an announced pre-licensing visit with administrator. Identification of the Applicant/administrator was verified by photo ID. The facility has a capacity of six (6). Application received for one (1) Ambulatory and five (5) Non-ambulatory- of which one (1) may be bedridden. Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following: The common areas (kitchen, living room, and dining areas) were appropriately furnished, and lighting was adequate. The facility has a variety of adequate perishable and non-perishable food supply. Appliances in the kitchen appeared to be functional. The living room has a television and comfortable furniture. The sharps are stored and locked in drawer in kitchen. Kitchen cleaning supplies, laundry detergents, and other toxins are stored in locked in garage storage cabinet. There are three (3) fire extinguishers: one (1) is located in kitchen attached to wall; one (1) in garage attached to wall and and extra fire extinguisher in garage. Fire extinguishers observed to be fully charged. Dual Smoke and Carbon Monoxide detectors were observed all over the facility, tested, and observed to be operational at time of visit. There is a functioning telephone/landline on the premises. An emergency exit plan/sketch is posted near each entrance/exit wall with other posting requirements. There are two (2) bathrooms in the facility. The Hot water was tested for resident bathroom and measured 105.6 and 106.7 °F. Bathrooms have non-skid mats, trash cans with lids and functional grab bars. There are four (4) resident bedrooms, designated as follows: (Cont from 809) B1: Ambulatory/Private- with bathroom B2: Non Ambulatory/Shared B3: Non-Ambulatory/Private B4: Non-Ambulatory/Shared No room is designated for staff use. Showroom bedroom observed to be appropriately furnished with a bed, nightstand, a chair, and each room has closet space. Extra linen stored in hall closet and bedroom #4 has own linen storage closet There is a covered patio for residents to conduct outdoor activities. The garage is attached with laundry area. Laundry appliances observed to be in good repair. There is no body of water on the facility. Component III was conducted with the administrator and administrator confirmed understanding of Title 22. At time of visit this facility is not ready to be licensed until the following item is verified · Outside/additional bathroom door in bedroom #1 door pending verification/may require update to facility sketch. This report will be forwarded to the Centralized Application Bureau (CAB). Exit interview was conducted and a copy of this report was provided.