Pre-licensing visit·July 23, 2025

Licensing Program Analyst (LPA), Regina Cloyd, 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 60 years and older. The requested capacity is for six (6) non-ambulatory. The facility has a fire clearance with the following special conditions: The rooms are approved for non-ambulatory/bedridden and approved for delayed egress or delayed egress with secured (locked) perimeter as of 06/18/2025. Fire alarm is required and the smoke detectors must be interconnected. Structure: Facility is a four (4) bedroom, two (2) bathroom, single story house. There is a large backyard and attached garage. Bedrooms Residents: Bedrooms #1 - 3 are for non-ambulatory residents. Bedroom #2 has two beds, one chair, one dresser, a closet and overhead lighting. Bedrooms #1 and #3 have one queen sized bed, one chair, adequate closet space, and overhead lighting. Bedroom #4 will be used by staff. Continue to LIC809-C. Bathrooms: Both bathrooms have a working toilet, wash basin, and step-in shower. Bathrooms will accommodate non-ambulatory residents in a wheelchair. Linens & Hygiene Supplies: Bedroom #2 has the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Additional linen is stored in the closet near bedroom #1. Emergency Phone Numbers, Exit Plan & Menu: There is a fire extinguisher located in the kitchen, garage and hallway near bedrooms #1 - 3. Food Service: Dishes, cups and flatware are stored in the kitchen cupboards, inspected and in good repair. Food supply adequately stored in the cabinets and refrigerator and consists of the following: canned goods, fruit, meat, and vegetables. Smoke Detectors & Carbon Monoxide Detector: Interconnected smoke detectors and one carbon monoxide near the kitchen pantry. Appliances: Stove burners, oven, microwave, washer, and dryer are working. There is one large refrigerator and small refrigerator for drinks in the kitchen. Each refrigerator has a measured temperature of at least 40 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is not equipped with central air and heat. Toxins: Locked/stored. Continue to LIC809-C. Water Temperature: Tested at 127 degrees. Medications, First-Aid Kit & Book: A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, and gauze, which are stored in the kitchen cabinet, available for staff use but inaccessible to residents. Reading Material, Games, Equipment & Materials: The facility has board games, reading materials, cards and puzzles for the residents' use. Pool/Jacuzzi & Pets: None. PRE-LICENSING CHECKLIST Not completed by the Licensee. COMPONENT III Information was provided about how to operate the facility within substantial compliance. During the prelicensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected, and proof of correction shall be submitted to the CCLD office to the attention of LPA Regina Cloyd (regina.cloyd@dss.ca.gov) by 08/12/2025. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction. Continue to LIC809-C. 1. The licensee shall have and maintain a current, written definitive plan of operation for the facility. The plan and related materials shall be on file in the facility. 2. Licensee shall prominently post facility’s policy regarding theft and investigative procedures, personal rights, additional personal rights of residents in privately operated facilities, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. 3. The facility shall be clean, safe, sanitary and in good repair at all times. 4. Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. 5. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 6. Slip-resistant mats, strips, or flooring shall be used in all bathtubs and showers floors. 7. A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for mattresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary. Continue to LIC809-C. 8. Bedroom furniture, which shall include, for each resident, a chair, nightstand, a lamp, or lights sufficient for reading, and a chest of drawers. 9. All outdoor and indoor passageways and stairways shall be kept free of obstruction. 10. All facilities shall have telephone service on the premises. 11. The Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. 12. A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. 13. A set of keys available to facility staff on each shift for use during an evacuation that provides access to all of the following: (C) All facility exit doors. 14. Plan for evacuation including: (A) Fire safety plan. An exit interview was conducted, and a hard 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.