Pre-licensing visit·February 8, 2023

Prelicensing: Licensing Program Analyst (LPA) Lizeth Villegas and Licensing Program Manager I LPM Janae Hammond, conducted an announced visit to the facility for purpose of a prelicensing evaluation. An application was submitted to CCLD for [Initial license] for a Residential care Facility for the elderly to serve [the Elderly] for [ages 60 and above. The requested capacity is for six residents (6) non-ambulatory, of which (1) may be bedridden, the facility has an approved hospice waiver for (6) residents, staff office, linen closet and a detached garage. Structure: – DESCRIBE THE STRUCTURES APPEARANCE AND LAYOUT, NUMBER OF BEDROOM, BATHROOMS, COMMON AREAS, OUTDOOR LAYOUT AND ACCOUTRAMENTS. Facility is a (4) bedroom, (3) bathroom, single house, 1 staff office, 1 linen closet and a (2) car de-attached garage. The facility is a beige stucco structure with 4 bedrooms, 3 bathrooms, 1 common room and a kitchen. There is a large outdoor shaded patio area. The client bedrooms are spacious and will easily accommodate the client's furnishings. All passageways, walkways, driveways, steps and patios are free from obstructions. Bathrooms: – 1 TOILET AND 1 WASH BASIN FOR EVERY 6 PERSONS INCLUDING CLIENT, FAMILY AND PERSONNEL, PER 85088(b)(1). NIGHT LIGHTS SHALL BE MAINTAINED IN HALLWAYS LEADING TO NON-PRIVATE BATHROOMS, PER 85088(e)(1). All bathrooms have a working toilet, wash basin, bath-tub/shower. Bathrooms will accommodate non-ambulatory clients in a wheel chair. Linens & Hygiene Supplies: – ADEQUATE SUPPLY MEANS LINEN SHOULD BE VARIED AND SUFFICIENT ENOUGH TO ALLOW FOR A CHANGE EACH WEEK OR AS OFTEN AS NECESSARY. “RUBBER OR PLASTIC SHEETING WHEN NECESSARY” PER 85088(c) & 85088(c)(4). Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supplied and stored in hallway linen closet. Emergency Phone Numbers, Exit Plan & Menu: – POSTED EMERGENCY DISASTER PLAN POSTED AND MEANS OF EXITING, PER 80075(k) & 80023(b). MENUS AVAILABLE UPNON REQUEST AND PREPARED ONE WEEK PRIOR AND DATED AS SERVED, PER 80076(a)(5). The facilities telephone system is an operational landline in the kitchen and in the staff office Posted & readily available for review in entry hallway are the emergency phone numbers and emergency plan. Fire Extinguisher located in kitchen area and mounted on wall, a second extinguisher is located staff office. Food Service: – NON-PERISHABLE ADEQUATE SUPPLY, MEANS STAPLE NONPERISHABLES FOR A MINIMUM OF ONE WEEK AND FRESH PERISHABLE FOR A MINIMUM OF TWO DAYS, PER 85076(d)(1). Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked drawer next to the stove. Food supply adequately stored in kitchen fridge and pantry. Dishwasher in kitchen properly installed and functioning. Smoke Detectors: – TEST ALL SMOKE DETECTORS IN THE HOME AS A MEANS TO ENSURE A SAFE AND COMFORTABLE ENVIRONMENT, PER 80072(a)(2). VERIFY THE PREMISES HAVE A CARBON MONOXIDE DETECTOR AS REQUIRED BY STATUTE. Electrical & connected and working. Carbon monoxide detector interconnected to smoke detectors. Appliances: – ALL APPLIANCES AND THE FACILITY SHALL BE IN GOOD REPAIR, PER 80087(a). LAUNDRY EQUIPMENT SHALL BE IN GOOD REPAIR, PER 85088(d). Stove burners, oven, microwave, washer, and dryer working. There are two refrigerators in the home, one in the kitchen and one in the garage for additional food storage. Each refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. Toxins: – ALL POISINS, CLEANING COMPOUNDS, TOXINS are STORED INACCESSIBLE TO CLIENTS, PER 80087(g). Locked and stored in kitchen cabinets and garage. Water Temperature: – TEMPERATURE SHOULD BE BETWEEN 105 AND 120 DEGREES IF FOR PERSONAL CARE, PER 80088(e). ALL TAPS DELIVERING TEMPERATURE GREATER THAN 125 DEGREES SHALL BE LABELLED AS SUCH, PER 80088(e)(2). All water tabs measured between 105 degrees to 120 degrees. Medications, First-Aid Kit & Book: – MEDICATIONS STORED UNDER LOCK AND KEY, PER 80075(n)(1). FIRST AID KIT AND CURRENT EDITION OF FIRST AID MANUAL, PER 80075(j)(1). A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in staff office and available for staff use but inaccessible to clients. Clients & Staff Files : – CLIENT RECORDS SHALL BE MAINTAINED CONFIDENTIAL, PER 80070(c). STAFF FILES SHALL BE MAINTAINED AT THE FACILITY SITE, PER 8006(e). Applicant will not be handling cash resources of clients. Reading Material, Games, Equipment & Materials: – ADEQUATE SUPPLES, NEWSPAPERS, MAGAZINES AND VARIED READING MATERIALS, PER 85088(g)(1). THEIR SHOULD BE SUPPLIES TO MEET THE PLAN OF ACTIVITIES, PER 85088(g). GAMES, SPORTS AND EXERCISE SHOULD BE AVAILABLE, PER 85079(a)(2). The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation. Fire clearance: – FACILITY SHALL SECURE A FIRE CLEARANCE, PER 80020(a). Fire Clearance was approved on 12/29/2022. Component III: – AN ORIENTATION PROCESS SHALL BE COMPLETED, PER 80018(b). Component III was completed on 02/08/2023 with Bessie L. Coello and Bessie Daniella Coronado-Allen to discuss information about how to operate the facility within substantial compliance. 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.