Pre-licensing visit·September 27, 2023

Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility at 8:40 am and was greeted and granted entry by designated Administrator (AD) Josephine Teehankee. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (1) non-ambulatory, and (5) bedridden clients was received by Community Care Licensing (CCL) on 9/9/2022. Structure: The facility is a two-story home with six resident bedrooms, four resident bathrooms, one staff bedroom, one staff bathroom, family room, kitchen, dining room, an attached two car garage and backyard. The second story of the home houses the staff bedroom and bathroom. LPA observed the door leading to the second story to be locked. Residents are not permitted to go upstairs. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the family room. There is an open office space for staff to use in the family room. LPA observed the office space to be free from hazards to clients. There is a back yard with two exit gates. The facility has two shaded seating areas. LPA did not observe any obstacles or hazards in the backyard. Client Bedrooms: All resident bedrooms had the necessary furnishings. LPAs observed all resident beds had linens and blankets. LPA observed all windows were screened. Each bedroom has a door leading outside. Each of these doors has an alarm that sounds upon the opening of the door. This sound will notify staff in case they need to check on the open door. Signal System: The facility utilizes a signal system for each resident. The monitor for the system is located in the dining room. Each resident is associated with a different number that will appear on the signal system’s monitor. The signal system also emits a sound and announces a different number associated with each Resident. Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked under the kitchen sink and in the garage. Medications, First-Aid Kit & Book: Medication and First Aid Kit will be stored in a locked closet in the dining room. The first aid kit has all the required elements. Resident & Staff Files: Records are kept in the medication closet as well as a cabinet in the family room. Fire Extinguisher: LPA observed one fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone. LPA observed the receipt for the fire extinguisher, indicating it was purchased on 8/17/23. Reading Material, Games, Equipment & Materials: The facility has books and games in the dining room. Fire clearance: Was approved by a fire inspector of Costa Mesa Fire and Rescue on 9/13/23. Bathrooms: The bathrooms have working plumbing. Hot water measured at 111.9 degrees Fahrenheit in bathroom 1, 112.4 degrees Fahrenheit in bathroom 2, 112.4 degrees Fahrenheit in bathroom 3 and 110.3 degrees Fahrenheit in bathroom 4. Linens & Hygiene Supplies: A supply of extra linen and hygiene supplies are stored in the garage. Emergency Phone Numbers, Exit Plan & Menu: Posted and available for review Food Service: There is 2-day supply of perishable and a 7-day of non-perishable food on hand. Smoke Detectors: Smoke detectors were observed to be dual Smoke & Carbon Monoxide detectors that are stationed throughout the home. The dual detectors were tested and observed to be operational. Appliances: Gas five burner stove with 1 oven, 2 refrigerators, dish washer, microwave, washer, and dryer are operational. The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.