Pre-licensing visit·April 8, 2022

Licensing Program Analyst (LPA) Jade Jordan, made an announced visit, and met with the Applicant /Administrator Richard De La Rosa to conduct a Pre-Licensing evaluation on Friday April 8, 2022, at 10:30 am. An application was submitted to Community Care Licensing Department (CCLD) on 02/02/2022 for an initial application to serve Individuals over ages 60 years, and above. The requested capacity is for five (5) ambulatory clients, zero (0) non- ambulatory clients, and one (1) bedridden clients. Structure: Facility is a one-story family home, located in a residential neighborhood, with six (6) bedrooms, (3) full bathrooms, living room, dining room, family room, Locked Medication room/ staff office, lock laundry and kitchen. A three (3) car locked garage is located in the front of the property, will be used for storage inaccessible to Residents. Front yard landscape is in good condition at time of visit and has an empty pond. Bedroom Residents: There shall be no more than two residents per bedrooms. Bedroom #1 are for ambulatory clients, and is a shared room, and has two beds. Bedrooms #2,3,4 will be for (1) one-ambulatory resident. Bedroom #5 is assigned for 1 bedridden resident. The 6 th bedroom is a staff room. All Bedrooms are equipped with a bed(s), night stand, chair, overhead lightning. All Bedrooms are located on sides, and back of the home. and bedroom 5 and is located towards the front right side of the house, near kitchen. Bedroom Staff : There will be live-in staff. *****************Continued on 809 C************ Bathrooms : (3) bathrooms have a working toilet, wash basin, bath-tub/shower. There is 1 half bathrooms, one is located in bedroom #1, and another in the staff room. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, fitted sheet, blanket and bedspreads, all rooms have required mattress pads. Ample supply of linen is stored in the closet. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers are posted, in the kitchen. Facility has a land line telephone located in the Dining, and family room area, currently active. One (1) fully charged fire extinguisher in the kitchen. Food Service: Dishes, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils will be stored in locked laundry storage. Ample food supply is stored in the kitchen and consists of the following: 7-day non-perishables, Emergency Canned food, and Emergency water. Smoke Detectors/Carbon Monoxide(s): There are electrical & connected smoke detectors and carbon monoxide; located throughout the facility fully operational. Appliances: Stove burners (gas) oven, dishwasher, microwave, and washer/dryer are in working condition. There is two (2) refrigerator in the home; located in the kitchen. The residence is equipped with central heat/air conditioning; and water heater located in laundry room. Toxins: Cleaning supplies, and toxins will be located in locked laundry room cabinet only accessible to staff. Water Temperature: Hot water was tested in bathroom #1 106.d which is within normal limits (105-120 degrees). Medication, First-Aid Kit & Book: Designated centrally stored medication will be locked and located in the locked medication room. Sufficient bandages, one (1) tweezer, one (1) thermometer, one (1) First Aid Manual, and one (1) pair of scissors. Clients & Staff Files : Designated area for files will be located in locked medication room. Applicant will not handle cash resources of Residents. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the Resident's use. Pools/Jacuzzi & Pets : No bodies of water and no pets on these premises, an empty pond was located in the front landscape. Fire Clearance: Fire clearance was approved on 02/21/2022, does not advise of any delayed egress features and/or any locked perimeters. Component III: Component III was completed at the Pre-Licensing on Friday, 04/08/2022 at 01:00Pm. Information provided about how to operate the facility within substantial compliance. The following individuals Richard De La Rosa, Administrator participated. When the applicant /administrator was asked if they have understood Title 22 he responded in the affirmative. During the pre-licensing inspection there were no items observed which do not comply with applicable laws and regulations. An exit interview was conducted, and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.