Pre-licensing visit·October 14, 2021

Licensing Program Analysts, Kathrina Chin and Beverly Thompson-Gracia made an unannounced visit for a pre-licensing evaluation. LPAs met with Charles Pham, Administrator. The facility has four bedrooms and two and a half bathrooms and is a single story with a two car garage. The inspection is as follows: A fire clearance was granted on July 28, 2021 for 6 non-ambulatory of which one may be bedridden. This facility has submitted a hospice waiver request for 1 resident. LPAs toured the facility, interior and exterior, including all resident bedrooms. Hot water were tested in a bathroom and observed to be 106 degrees Fahrenheit. Fire extinguishers were mounted and charged. Smoke detectors were centrally wired throughout and have been checked by the fire department. Carbon monoxide detectors are operational. There is a sufficient supply of linens. Bedrooms are appropriately furnished. There is sufficient lighting. There are non-skid mats in the showers. There was one locked medication closet which stores two first aid kits. There were several locked closets for storage of toxins, cleaning equipment, PPEs in the garage. All exit has auditory devices. The kitchen area was checked and there is a sufficient supply of food items. There were emergency food supplies and water. LPA observed activity calendars, theft and loss policy, residents rights, admission agreement, and emergency plans were posted including the Ombudsman and Let Us Know posters. LPA reviewed the outdoor area and with outdoor furniture. A Component III was completed during the visit with Charles Pham, Administrator. LPAs reviewed Personnel Policies, Prohibited Health Conditions, Fingerprinting, Abuse Reporting Procedures, In-Service Training and Medication Procedures. (Continued LIC 9099C) It appears that this facility meets the requirements for licensure. Both the license and the hospice waiver will be granted upon final review and approval from the Central Applications Bureau. An exit interview was conducted with Administrator, Charles Pham and a hard copy of this report was provided.