Pre-licensing visit·August 5, 2025

Licensing Program Analyst (LPA) Evelin Rios conducted a Pre-Licensing Inspection with the applicant/administrator, Marian Antona. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 01/07/2025. This is a change in ownership (CHOW) application. The current census for active license is three (3). All three (3) residents and their responsible party have been notified of CHOW. A fire clearance was approved on 04/04/2025 for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six (6). At entrance LPA observed required postings by the front door and a sign in folder for visitors.. A tour of the physical plant was initiated at approximately 11:45 a.m., and the following was observed: KITCHEN: The kitchen is equipped with a refrigerator, stove/oven, dishwasher and microwave. The facility has a sufficient amount of two day perishable and seven day non perishable supply of food. The facility has dishware and cook ware for the capacity of the facility. Knives are kept locked in a kitchen drawer. Cleaning supplies are kept locked in bottom cabinets by the dining area. BEDROOMS: There are six (06) total bedrooms. Five (05) bedrooms are designated for residents use. Bedroom labeled #5 is for staff only. Per STD 850, rooms #3 is cleared for one (01) bedridden resident. Bedrooms designated for resident use have appropriate furniture with sufficient lighting and storage space. The smoke alarms and carbon monoxide detector are dual, hard wired and inter-connected. Administrator tested detectors at 11:59 a.m, and they were observed working properly. The facility has one (01) fire extinguisher located by the dining area with purchase date 11/25/2024. (Continue to LIC809-C) Backyard: There is sufficient space for outdoor activities and appropriate outdoor furniture. There are no bodies of water. There are two (02) sheds that are maintained locked. Entrance/exits are clear of obstruction. The facility is completely fenced. BATHROOMS: The facility has three (03) bathrooms. Two (02) bathrooms are designated for resident use and one (01) is located in a shared bedroom for private use. Bathrooms were observed to have proper fixtures, grab bars, and non-skid mats. The hot water temperature was measured at 115 degrees Fahrenheit. Common Areas: Furniture such as the dining table, chairs and couches were observed in good repair. Both living room and dining room have sufficient space and lighting. No tripping hazards observed. Passageway to exits are free of obstructions. Garage: The garage is attached to the building. Entrance to the garage is through the laundry room that is maintained locked. Laundry detergent is kept in the locked laundry room. The laundry room is equipped with a washer and dryer. In the garage LPA observed a deep freezer and facility supplies such as, cleaning supplies and emergency water. Resident/Staff Records: Facility records, centrally stored medication and medication records are kept in a locked cabinet in the living area. At approximately 12:53 p.m., LPA reviewed three (03) out of three (03) resident records and three (03) staff records. Component III was held with applicant/administrator, Marian Antona. Pre-Licensing is complete and no deficiencies were observed. This report will be sent to Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when the license has been approved. Exit interview was conducted. A copy of this report was signed and provided.