Pre-licensing visit·May 21, 2025

At approximately 3:15 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a pre-licensing inspection and was greeted by staff. David Cervantes Vibat, Licensee was contacted via telephone and arrived approximately 90 minutes later. This pre-licensing inspection is being conducted for a change of ownership of a Residential Care Facility for the Elderly (RCFE). Fire Clearance has been approved for 6 ambulatory residents. Facility has a dementia care plan and a Hospice waiver for two (2). Licensee/Applicant uses a placement agency. At approximately 3:45 PM, LPA initiated a tour of the facility and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed resident showers with the required non-slip mats and grab bars in place. LPA observed a supply of clean linens, hygiene products, and paper products available for residents. Facility has seven (7) bedrooms; six (6) are resident bedrooms and one (1) is a staff bedroom. Residents' bedrooms have the appropriate furnishings as outlined in Title 22 regulations. There are dishes and cooking supplies for resident use with sharps and other hazardous items kept secured in various designated drawers and cabinets. Cabinets in communal areas of the facility containing cleaning supplies and other items that could pose a risk were observed locked. Facility has at least two days of perishable foods and at least one week of non-perishable foods and an emergency water supply. Continued on LIC809-C... ...continued from LIC809... Licensee has a sample menu in the common area to indicate a healthy and balanced set of meals for residents in care. The facility has a land line which was tested and operational during inpsection. Facility has an internet access device designated for resident use and has internet services. Facility has a designated locked closet for centrally stored medications. LPA observed the facility's infection control plan, first aid kits, PPE, other emergency supplies, and games and activities available for resident use. Facility has a fully charged fire extinguisher, which was last inspected 07/2024. Smoke and Carbon Monoxide detectors were unable to be tested during inspection. Licensee/Applicant will post a hard copy of their administrator's certification and emergency disaster plan. Facility sketch, personal rights information, ombudsman poster and reporting poster are in facility communal areas. Licensee has been informed of association and staff transfer process and agrees to ensure all staff are cleared and associated. The backyard features ramps and walkways for residents. Windows, screens, and blinds are all found to be in good repair. Licensee/Applicant submitted a copy of the facility's lease agreement to the Centralized Application Bureau and agrees to submit proof of liability insurance upon licensure. LPA observed a facility sketch which accurately reflects the floor plan. LPA will return to complete pre-licensing visit, file review and conduct the Component III orientation with the Licensee/Applicant. Exit interview conducted with Applicant, whose signature on this document confirms receipt .