Pre-licensing visit·July 28, 2023

Licensing Program Analyst (LPA) Jose Villalobos conducted an announced visit with applicant Iwona Kaya. Applicant Stefanie Skormorucha was present via facetime. The purpose of the visit was to conduct the Pre-Licensing for the facility listed above. An application was submitted to CCLD on 12 /6 /2022, for a Change of Ownership of a Residential Care Facility for the Elderly for ages 60 years and older. The requested capacity of 6 residents, (0) ambulatory, (6) non-ambulatory and (0) may be bedridden and Hospice Waiver up to (4) residents. Structure/Physical Plant: The facility is part of a single story home located in a residential area and contains the following: living room, dining room, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, locked storage cabinet for medications and sharps, (4) resident rooms, (1) live in staff room (2) bathrooms for residents and (1) bathroom for the live in staff; bathrooms with shower, toilet and washbasin. A back yard with shaded area and seating for resident use. A connected garage inaccessible to residents for storage and Laundry; with washer and dryer. The residence is equipped with air conditioning in each room. The facility is currently operating under facility # 198602532 and has 6 residents in the facility. Accommodations : Adequate accommodations observed throughout facility. Lighting: Sufficient Lighting throughout. Hallway and Doorways: Free and clean of obstruction and debris. Resident Rooms: Bedrooms #1-#4 are for non ambulatory residents. Bedroom #5 is used for live in staff. All bedrooms are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, and closet space, and beds for each resident. Bathrooms: Bathroo m #1, # 2 have a working toilet, wash basin, shower, grab bars and nonskid mats. Continued on LIC 809-C Linens & Hygiene Supplies: Required linen/supplies which include, pillowcase, fitted sheet, blankets, bedspreads. Mattress pads were observed. Emergency Phone Numbers, Exit Plan & Menu: Facility has a working phone landline. There are (2) cordless phone for residents use. Fire Extinguisher 1 and 2 fully charged and up to date Food Service: All food and adequate utensils such as, dishes, cups, bowls and plates are stored at the other location until residents move in. Knives, cutlery and other sharps inaccessible to residents will be kept in a locked cabinet. Smoke Detectors & Fire Extinguishers: Detectors Electrical & connected. Battery operated & working. Smoke detectors and also carbon monoxide detectors observed, all detectors tested and operational. (2) Fire extinguishers observed and up to date. Appliances: Stove burners and oven operational. Microwave, washer, and dryer are operational. Toxins: Locked/stored for staff use only. Hot Water Temperature: Measured between 110 -120 degrees all around the home. Medications, First-Aid Kit & Book: Medications centrally stored and inaccessible to resident. First aid kit inspected which contains: thermometer, tweezers, scissors, antiseptic, bandages, gauze, which is available for staff use. First Aid Manual observed. Residents & Staff Files : Facility has a locked cabinet for resident and staff files. Current files for residents #1-#6 observed. Reading Material, Games, Equipment & Materials, Postings: The facility has activity supplies and an activities calendar posted. Required wall postings observed. Bodies of Water: None. Pets: None. Fire clearance: Fire clearance was approved on 4/19/23. Physical Plant cleared at the time of this visit. Component III: Component III was conducted at the time of this visit. An exit interview was conducted and a copy of this report has been furnished to the applicant Iwona Kaya. 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