Pre-licensing visit·July 3, 2025

At approximately 9:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived announced to conduct a pre-licensing inspection and was greeted by House Manager, Raymond Go. Ali Sina Dastghheib , Licensee/Administrator was contacted via telephone, gave permission to begin inspection with House Manager, and arrived approximately 90 minutes later. This pre-licensing inspection is being conducted for a change of ownership licensing of a Residential Care Facility for the Elderly (RCFE). Fire Clearance has been approved for 5 non-ambulatory and 1 bedridden resident. Licensee/Administrator applied for a Hospice waiver for 2 which is being reviewed and has a dementia care plan. Licensee/Applicant works with a placement agency. There were 5 residents in care during today's inspection. At approximately 9:30 AM, LPA initiated a tour of the facility with House Manager 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, incontinent care products, and paper products available for residents. Hallways are equipped with night lights and residents' bedrooms have all the appropriate furnishings as outlined in Title 22 regulations. There was a sufficient amount of dishes and cooking supplies for resident use with sharps and other hazardous items kept secured in various designated drawers and cabinets as well as under the kitchen sink. Continued on LIC809-C... ...continued from LIC809... 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, one week of non-perishable foods, and an emergency water supply. LPA observed a sample menu posted in the common area to indicate a healthy and balanced set of meals for residents in care. The facility telephone was tested and is operational. Facility has internet services and an internet access device designated for resident use. Facility has a designated locked closet for centrally stored medications and resident, staff, and facility files. LPA observed the facility's infection control plan, first aid kits, PPE, other emergency supplies, and an activity schedule. LPA recommended increasing activity supplies and frequency. The backyard features a deck and paved patio area with shaded seating for resident outdoor use. Windows, screens, and blinds are all found to be in good repair. Facility has 2 fire extinguishers, which were last inspected 06/2024 and are fully charged. Facility has a third party company scheduled for 7/7/2025 to service extinguishers. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Licensee/Applicant has posted hard copies of the emergency disaster plan and maps, personal rights information, local ombudsman information, and the CCLD reporting poster in facility communal areas. The facility currently has Licensee/Applicant and one staff member associated to facility. Other staff are cleared and associated under the existing facility and Licensee/Applicant agreed to associate the staff to the new facility license with Guardian. Licensee has been informed of association and staff transfer process. A sampling of staff and resident files were reviewed and found to be in compliance with regulation. Medications and medication records were inspected and found stored and maintained in compliance with regulation. Licensee/Applicant submitted a copy of the facility's lease agreement to the Centralized Application Bureau and will submit proof of liability insurance once plan is active post licensure. LPA observed a facility sketch which accurately reflects the floor plan. LPA observed three structures in the backyard which are noted on facility sketch but the fire department inspector did not specify the approved use of any as living quarters. LPA contacted Fire Inspector for clarification. Licensure pending confirmation that the blue and white structure is approved as living quarters for staff as observed with made bunk beds, furniture, clothing, and personal items during today's inspection. Component III orientation was conducted with the Licensee/Applicant at facility where they conveyed knowledge and understanding of Title 22 regulations. The pre-licensing evaluation has been completed. Exit interview conducted with Applicant, whose signature on this document confirms receipt .