Pre-licensing visit·June 3, 2021

Licensing Program Analyst (LPA) Michelle Reed contacted the facility via telephone to commence an announced Prelicensing visit. Upon arrival, LPA met with Moneli Sharifan. An initial application to operate an Residential Care Facility for the Elderly was submitted to the Central Applications Unit (CAU) on 1/25/21 for a capacity of 6 residents of which 1 may be bedridden. The Orange County Fire Department conducted a Fire Safety Inspection on 3/3/21 and granted a fire clearance. A tour of the physical plant was conducted inside and out at approximately 9:30am with Ms. Sharifan and the following was observed: Structure: Facility is a one story house with 5 bedrooms and 3 bathrooms. There is a gate that slides across the driveway of the house. Ms. Sharifan understands that the gate may not be locked as the facility was not approved for locked perimeters. Side gates for exits also may not be locked. Bedroom #1 through #5 are designated as resident rooms and are authorized for non-ambulatory resident use. There is also a living room, dining area and kitchen. There a staff room next to the kitchen and laundry room. Signal System: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: The resident bedrooms( #1-#5) accommodate residents' furnishings and meet Title 22 regulation at this time. Bedrooms with stair exits have hand rails and ramps were present and will be installed. Bathrooms: 3 bathrooms have a working toilet, wash basin, and shower. The 3rd bathroom is for staff and visitors only. Grab bars and non-slip mats were present. Linens and Hygiene Supplies Adequate supply of linens and hygiene items were observed Ombudsman Poster, Personal Rights and See Something Say Something Poster Applicant will request an Ombudsman poster. Personal Rights and See Something Say Something were posted. Food Service: Adequate supply of 7-day non-perishable and 2 day perishables will be stored in the kitchen and pantry and will include fruits and vegetables. Smoke and Carbon Monoxide Detectors: Smoke detectors and carbon monoxide systems were observed working at the time of this visit Fire Extinguishers: The fire extinguisher was mounted and fully charged at the time of this visit Fire Clearance: Approved on 3/3/21 Appliances: Refrigerator/freezer and microwave which were clean and noted to be operational. Washer and dryer were clean and noted to be operational. Toxins: Will be locked and inaccessible to residents Water Temperature: Tested and recorded at 118 degrees F. Medications, First Aid Kit & Manual: First Aid kit with guide will be stored with resident medications. Medication will be stored and locked in the facility living area. Resident and Staff Files: Records will be kept locked for privacy Component III Component III was conducted The Prelicensing is complete and this facility has no deficiencies. The Licensee will be granted upon a final review by the Central Applications Bureau and approval by management. An exit interview was conducted and a copy of this report was provided to Moneli Sharifan..