Pre-licensing visit·June 9, 2021

Licensing Program Analyst (LPA) Michelle Reed arrived at facility the house to commence an announced Prelicensing visit. Upon arrival, LPA met with Cosmin Surgent. An initial application to operate an Residential Care Facility for the Elderly was submitted to the Central Applications Unit (CAU) on 4/2/21 for a capacity of 6 non-ambulatory residents of which 1 may be bedridden. The Anaheim Fire Department conducted a Fire Safety Inspection on 5/5/21 and granted a fire clearance. A tour of the physical plant was conducted inside and out at approximately 12:15am with Mr. Surgent and the following was observed: Structure: Facility is a one story house with 7 bedrooms and 4 bathrooms. Bedroom #1 through #6 are designated as resident rooms and are authorized for non-ambulatory resident use. Bedroom #6 will be the bedridden room and #7 will be for staff. There is also a living room, dining area and kitchen. The yard has a shaded area for residents to enjoy the outside and applicant will have patio furniture and a canopy for residents to enjoy. Signal System: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: The resident bedrooms( #1-#6) accommodate residents' furnishings and meet Title 22 regulation at this time. Bedrooms have slider doors and ramps to the outside. Bathrooms: 4 bathrooms have a working toilet, wash basin, and shower. The 4th bathroom near the kitchen is for staff and visitors only. Grab bars and non-slip mats were observed in all. 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 as well as the facility sketch 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. LPA observed non-perishables on today's visit.. 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 5/5/21 Appliances: Refrigerator/freezer and microwave which were clean and noted to be operational. Washer and dryer were clean noted to be operational. Toxins/Sharps: Will be locked and inaccessible to residents Water Temperature: Tested and recorded at 120 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 Cosmin Surgent.