Pre-licensing visit·April 6, 2022

Licensing Program Analyst (LPA) Vasallo conducted a prelicensing visit. LPA met with applicant Tiffany Vander Poorten. The applicant is a current licensee and therefore a component III is not required. This property has never been licensed. The fire clearance has been approved for 6 non-ambulatory residents and 0 bedridden residents. The applicant has requested to care for dementia residents and has submitted a waiver for 6 hospice residents. The physical plant was toured with the applicant. The following was observed. There are auditory devices on exit doors as required for dementia residents. Smoke detectors were observed in common areas and in each resident bedroom. There are 3 carbon monoxide detectors. 1 in the hallway, 1 in the laundry room and 1 in the dining room. The garage is detached from the home and was observed to only be used for storage. The garage has another refrigerator for extra food. Medications will be stored in a locked cabinet near the dining room. The home has a complete first aid kit located in the laundry room. Window screens are in good condition and there were no obstructions near doors. Windows do not have security bars. There are 4 bedrooms for residents and 0 staff bedrooms. Two of the resident bedrooms are shared rooms, and 2 are private rooms. Resident rooms were observed to have the required furniture such as bed frames, dressers, chairs, lamps and sufficient closet space. The bedding was also appropriate. The home has 3 bathrooms. The bathrooms have the required grab bars in the shower and near the toilet along with the required non-slip mats. There is sufficient lighting throughout the home including common areas and resident bedrooms. There is a fire extinguisher near the kitchen and another in the laundry room. The hot water temperature was 118.2 degrees, which is within the required 105 - 120 degrees. All appliances in the kitchen were observed to be clean and operational. The sharp knives are located in a locked kitchen cabinet. Cleaning supplies will be stored in a locked kitchen cabinet under the sink. The backyard has a shaded patio area with patio furniture. The home does not have a pool or any large bodies of water. The home has all the required posters. There are no cameras inside the home. No records were reviewed since the home has never been licensed. Per California Code of Regulations, Title 22, the home meets the physical plant requirements. Exit interview held and a copy of the report was provided to applicant.