Pre-licensing visit·August 20, 2025

O n 08/20/2025 at 9:20am, Licensing Program Analyst (LPA) Zina Brown conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA Zina Brown met with applicant Riza In, Administrator/ Licensee. An application was submitted to CCLD on 01/03/2025, for an Residential Care Facility for the Elderly (RCFE) to serve elderly residents and dementia adults for ages 60 and over. The requested capacity is for six (6) residents of which five (5) are non-ambulatory and one (1) is bedridden. Structure: The facility is a (5) bedroom, (2) bathroom, single story house with a  attached garage. The facility is a  structure with 5 bedrooms, 2 bathrooms, 1 living room with a TV, a kitchen, and a backyard accessible to residence. There is backyard has an outside shaded patio area. The resident five (5) bedrooms are spacious and will easily accommodate the residence furnishings. Bedroom Structure All five (5) bedrooms have the following one (1) bed, one (1) lamp, one(1) dresser and or closet, and one (1) one (1) chair. In bedroom #5 the exit door has a signal auditory alarm. Bathroom Structure All two (2) bathrooms have a working toilet, wash basin, shower with a rail and a slip grip ma. All (2) bathrooms can accommodate non-ambulatory clients in a wheel chair. Water temperature for each bathroom are as followed bathroom #1 at 110.8 °F and bathroom #2 at 112.6°F Report continues on LIC 809-C Component III: During the conducted pre-licensing visit, between the hours of 9:21am - 9:28am an orientation of the component III information was provided to the licensee 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 Zina Brown 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. Toxins: All toxins are locked and stored in. Water Temperature: The water in each bathroom tested at 110.8 °F (bathroom 1), 112.6 °F  (bathroom #2) and 110.5 °F (in kitchen) Medications, First-Aid Kit & Book: 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 hallway area, available for staff use but inaccessible to residence. Residents & Staff Files: At the time of pre-licensing, no resident and staff files were reviewed as the facility is awaiting approval for licensing. Reading Material, Games, Equipment &  Materials: The facility hasbooks, and other recreational materials for the resident 's use and commensurate with the plan of operation. Pool/Jacuzzi & Pets : No located at the time of inspection. Fire clearance: Fire clearance for six (6) residents of which five (5) residents can be non-ambulatory and one (1) resident can bedridden at the residential care facility for the elderly was approved on 01/28/2025. In one of the five bedrooms there is a exit door with a auditory alarm in bedroom # 5 which is the assigned bedridden room. Pre-licensing Checklist: Completed by licensee and reviewed by LPA. Report continues on LIC 809-C Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in main entry area of the home. Emergency Phone Numbers, Exit Plan & Menu: The facility has a working phone line and internet. Upon entering the facility there, is a posted board that is readily available with a evacuation plan, fire prevention, emergency plan, infection control plan and personal righst. Fire Extinguisher is located near kitchen mounted on wall which is fully charged. Food Service: 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 cabinet near the refrigerator. Food supply adequate stored in cabinet and consists can goods. The water temperature in the kitchen is at 110.5 °F. Dishwasher in kitchen properly installed and functioning. Smoke Detectors: In the facility there are nine (9) smoke detectors with carbon monoxide detectors that are electrical & connected. Battery operated & working. Appliances: In the facility is a working stove burners, oven, microwave, washer, and dryer. There is one (1) refrigerator in the kitchen that is measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at 0 zero degrees Fahrenheit. The residence is equipped with central air and heat and each resident bedroom is individually climate controlled. Report continues on LIC 809-C