Pre-licensing visit·January 7, 2022

Licensing Program Analyst (LPA) Michelle Reed arrived at the facility to commence an announced Pre-licensing visit. Upon arrival, LPA met with Cynthia Shoga. Mrs.Shoga will be the designated Administrator. An initial application to operate an Residential Care Facility for the Elderly was submitted to the Central Applications Unit (CAU) on 11/4/21 for a capacity of 6. Capacity will be 5 non-ambulatory, 1 ambulatory and 1 bedridden resident. The Orange County Fire Authority conducted a Fire Safety Inspection on 11/8/21 and granted a fire clearance. Room #4 was approved for a bedridden resident and #6 was approved for ambulatory residents only. The facility is not approved for locked perimeters. The facility will be a change of location and there were 4 residents present. A tour of the physical plant was conducted inside and out at approximately 1:30pm and the following was observed: Structure: Facility is a one story house with 6 bedrooms and 4 full bathrooms. Bedroom #1, #2, #3, #4, #5 and #6 are designated as resident rooms. There is also a living room, dining area, laundry room and kitchen. There is a staff resting room just outside the storage closet near Room #1. There are fountains in the front and backyard that meet Title 22 regulation. Shade was provided on the patio. COVID19 mitigation procedures were also discussed with the Applicant. The discussion included: Social distancing, mask requirements, temperature checks, as well as the posting of signs. A hand sanitizing station was present for visitors and staff at the front door. Applicant stated that she has plenty of PPE(gloves, masks, hand sanitizer) Signal System: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: The resident bedrooms accommodate residents' furnishings and meet Title 22 regulation at this time. Bathrooms: Bathrooms have a working toilet, wash basin, and shower. Grab bars and non-slip mats were present. Linens and Hygiene Supplies: Adequate supply of linens was observed Ombudsman Poster, Personal Rights and See Something Say Something Poster Ombudsman poster, Personal Rights and See Something Say Something posters were posted. Food Service: Adequate supply of 7-day non-perishable and 2 day perishables are stored in the kitchen and pantry and includes fruits and vegetables. LPA observed food in pantry. 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 Appliances: Refrigerator/freezer and microwave were clean and noted to be operational. Washer and dryer were clean and noted to be operational. Toxins: Locked and inaccessible to residents Water Temperature: Water Temperature was measured at degrees F. Medications, First Aid Kit & Manual: First Aid kit with guide is 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 Pre-licensing is complete and this facility has no deficiencies. Corrections to the sketch will be provided. The License will be granted upon a final review by the Central Applications Bureau and approval by management. An exit interview was conducted with Cynthia Shoga and a copy of this report was provided.