Pre-licensing visit·September 12, 2025

Licensing Program Analyst (LPA) Cynthia Chan conducted an announced visit to the facility for a pre-licensing evaluation. An application was submitted to CCLD on 8/13/24 for an initial license for a Residential Care Facility for the Elderly to serve the Elderly, ages 60 years and older. The fire clearance is approved for six (6) non-ambulatory residents ages 60 and over. The applicant has submitted a request for a hospice waiver to the Centralized Applications Bureau (CAB). LPA used the Compliance and Regulatory Enforcement (CARE) tools to conduct the inspection. Infection Control: The licensee has an Infection Control Plan and a lead staff designated to conduct training. Facility has sufficient PPE supplies. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. The licensee will secure the liability insurance at $1,000,000 per occurrence and $3,000,000 total aggregate upon licensure. Structure/Physical Plant: The facility is a single-story home with 4 resident bedrooms (bedrooms #1 and #3 are private, and #2 and #4 are shared), 2 bathrooms, a living room, dining room, kitchen, family room, and attached garage. The bathrooms have non-skid mats in the shower area and grab bars. The facility has interconnected smoke detectors and carbon monoxide detectors throughout the home. The fireplace has a secured fence and will not be in use. Knives and sharp objects are locked in the kitchen cabinets. Cleaning solutions are locked and stored in the garage. The backyard has a covered patio with a table and chairs. The facility has auditory devices located on each exit door. There is no swimming pool on the premises. Surveillance cameras are observed in the common areas. Food Service : There is a sufficient food supply of at least a week of non-perishable food maintained at the facility. The licensee will purchase the 2-day perishable items before admitting a resident. The kitchen is kept clean and sanitary. All the appliances are in working order. A sufficient amount of tableware, dishes, and utensils is observed. The refrigerator is maintained at 40 degrees F or below, and the freezer at 0 degrees F or below. Staff and Residents files: Staff and Residents' files will be maintained at the facility. Resident Rights/Information: Resident rights, Resident councils, and complaint posters are posted in a prominent area. Planned Activities : The facility has sufficient space to accommodate indoor and outdoor activities. Incidental Medical and Dental: Medications will be centrally stored in the kitchen cabinet. The first aid kit contains all the required supplies along with the current first aid manual. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: The facility accepts and retains residents with dementia. The facility landline is (626) 638-3428. Component III was conducted during the visit today. The physical plant is cleared, and no correction is needed. However, the applicant will submit the following to the CAB for review: · Surveillance cameras in the facility - update plan of operation · Hospice Waiver An exit interview was held, and a copy of this report was given to the applicant.