Pre-licensing visit·April 7, 2025

Licensing Program Analyst (LPA) Mariana Agban conducted a Pre-Licensing Inspection with Administrator Salvacion Butler. A Change in Ownership (CHOW) Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on July 19, 2024. A fire clearance was approved on January 3, 2025, for five (5) non-ambulatory residents and one (1)bedridden resident, for a total capacity of six. The bedridden fire clearance is for room #1. A dementia plan of operation has been submitted. A hospice waiver has been requested for six (6) residents pending the Manager's approval. The smoke alarms and carbon monoxide detector are battery-operated and functional. The facility has multiple fire extinguishers with a service date of 09/05/2024. The fire extinguishers are located in the dining room, kitchen, second hallway area, and by the garage. A tour of the physical plant was initiated at approximately 10:10 am and the following was observed: KITCHEN : The facility has a Kitchen area equipped with a refrigerator, microwave oven, and sink. Adequate supplies of perishable and nonperishable food and dining ware accommodated a maximum capacity of six (6). BEDROOMS : There are five (5) bedrooms designated for residents' use. Bedrooms #2, #3,#4, and #5 are private rooms for non-ambulatory residents. Bedroom#1 is a shared room bedroom with one (1) bedridden resident as per the fire clearance approval. The applicant furnished the resident bedrooms with beds, nightstands, chairs, dressers, bedding, and linen. The bedrooms have sufficient lighting and closet space. (Continue on 809C) BATHROOMS: The facility has two (2) bathrooms for the residents' use. Both bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured 110.3 degrees. No cleaning supplies or hazardous items were present in each bathroom. COMMON AREAS: These included the living room and dining room. The living room was equipped with furniture, a television, tables, and chairs. The dining area has a large dining room table to accommodate six (6). There is a fireplace in the family room. It is screened, and there are no tools. There were no visible immediate hazards. There is a functioning telephone on the premises in the living room. Medications are kept locked in the living room cabinets. There is also an office/workstation area in the living room. LAUNDRY ROOM/GARAGE: The washer is located by the kitchen area, and the dryer is located in the garage. The garage is used as extra storage for non-perishable and emergency food supplies and water. There is another refrigerator in the garage for additional perishable food items. Laundry detergents are kept locked in the garage and inaccessible to residents. Resident Files: LPA conducted a file review of random resident records to ensure compliance with licensing forms. Staff Files: Staff files are also kept in a locked cabinet in the living room. SURROUNDING GROUNDS : The driveway, passageways, and entrance to the home were clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The backyard of the facility has a patio and backyard furniture to accommodate the six (6) residents. The facility's backyard has sufficient yard space. In addition to the Pre-Licensing inspection, a Component III power point presentation was also held. Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised and a copy of this report provided.