Pre-licensing visit·January 11, 2023

Licensing Program Analyst (LPA) Luis Mora conducted an announced Pre-Licensing visit. LPA met with Marilyn Mirabueno (Licensee) and Buenomir Mirabueno (Administrator) and explained the reason for the visit. A change of ownership application was submitted to Community Care Licensing Department (CCLD) for a Residential Care Facility for the Elderly (RCFE) to serve 6 non-ambulatory residents, in which 1 may be bedridden, in the age range of 60 and over. Facility is approved for 6 hospice waivers. The facility is in a residential area and it is a one story family home. A tour of the single-story facility included the 4 resident bedrooms, 1 staff room, 2 bathrooms, living room, kitchen, laundry room, attached garage, front yard and back yard. LPA Mora conducted the tour with Marilyn Mirabueno and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Kitchen appliances are clean and were operating at the time of the visit. Sharps were observed locked in the medication cabinet. Chemical and cleaning solutions are kept locked in the laundry room and bathrooms. The First Aid kit is kept locked in the medication cabinet and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in the hallway closet. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a kitchen cabinet. All bedrooms have all required furniture, lighting, and bedding. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. The showers have non-skid materials. Auditory devices were seen on all exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in both bathrooms and measured at 114.4 degrees F and 114.0 degrees F, which is within the required 105-120 degrees F. Fire extinguishers were observed in the kitchen and garage, and are fully charged. Smoke detectors and carbon monoxides were observed throughout the facility and were operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction. Fireplace has a screen cover. Resident and staff files are kept locked in a living room cabinet. (CONTINUED TO LIC 809C) LPA reviewed medication for all 4 of the residents and observed that medications were given as prescribed. LPA reviewed files for all 4 of the residents and observed no deficiencies. LPA reviewed 4 staff files and observed no deficiencies. LPA observed an administrator certificate for Buenomir R Mirabueno – 6054728740 with an expiration date of 12/29/2023. Facility has 30 days supplies of Personal Protective Equipment in the laundry room. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed. No outstanding or pending items were observed by the LPA requiring additional pre-licensing visits. LPA will notify the assigned Centralized Applications Bureau (CAB) Analyst of the completed pre-licensing facility evaluation visit conducted, which included the Component III Orientation. Exit interview conducted and a copy of this report was provided to the administrator.