Pre-licensing visit·January 26, 2022

Licensing Program Analysts (LPAs) Jey Cardenas and Antonia Alvizar made an announced visit, and met with the Applicant, Michelle Ann Porca also present was back up administrator Jon Camlas. LPA Cardenas conducted a risk assessment, based on the assessment, the facility is clear of Covid-19 infection. An application was received by Community Care Licensing Department (CCLD) on 09/14/21 for an initial application to serve residents ages 60 and over. The requested capacity is for total six (6) residents, of which five (5) may be non-ambulatory and one (1) bedridden. Rooms #2 and #4 approved for bedridden resident. Structure The facility is a one story home in a residential neighborhood. The facility has a living room, dining area, kitchen, office, seven (7) bedrooms of which six are designated for residents and one (1) is for staff. Four (4) bathrooms, garage with laundry space. Facility has one working telephones located in the kitchen. Beds have required lines/ supplies pillowcase, fitted sheets, blankets, Bathrooms: bathrooms have working toilet, sink, and standing showers. Secured grab bars and skid mats observed. Food Service: Sufficient plates and cups were observed in the home, Knives, cutlery, and other sharp kitchen utensils are inaccessible and under lock. Full charged fire extinguishers located throughout the facility. Smoke Detectors/Carbon Monoxide(s): LPA observed dual/ hardwired with battery back up smoke detectors/ carbon monoxide mounted on ceiling located in the kitchen, hallways, and bedrooms. Appliances: there is a microwave, one working refrigerators, toaster, microwave, water dispencer, and rice cooker available. Toxins: Cleaning supplies and toxins are stored near separate kitchen bottom cabinet which remains locked. Water Temperature: Hot water was tested in residents bathroom on both ends of facility, water measured at 119.1 and 107.9 degrees Fahrenheit. Medication, First-Aid Kit & Book : LPA observed standing cabinet located in the office which will be used for medication. First aid kit, and first aid book available at time of visit. Clients & Staff Files: Designated area for files are located in a locked file cabinet located in office area. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. No fire arms in the home. LPA observed activities, board games for residents. Fire Clearance: Fire clearance was approved on 12/14/21, fire clearance granted. Facility is equipped with auditory alarm devices in exits. Facility will not handle residents cash resources. Component III ; LPAs reviewed component III with applicant. When the applicant was ask if they understood Title 22 regulations they responded in the affirmative. An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPAs will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application. Pre Licensing is complete and has no corrections to make.