Pre-licensing visit·March 24, 2023

Licensing Program Analysts (LPAs) Claudia Gutierrez and Dwayne Mason made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPAs arrived at the facility and were greeted and granted entry by designated Administrator (AD) Ryan Roche, and Assistant Administrator Scott Messick. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden residents was received by Community Care Licensing (CCL) on 12/08/2022. Structure: The facility is a single-story house with five resident bedrooms, two bathrooms, living room, kitchen, staff bedroom, walk-in hallway closet, laundry room, and an attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the living room area. There is a back yard with one exit gate on the side of the house. LPA did not observe any obstacles or hazards in the backyard. Client Bedrooms All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. Signal system There is no signal system. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked beneath the kitchen sink and in the laundry room. Medications, First-Aid Kit & Book: Medication will be stored in a locked closet. First aid kit is stored with the medication. The first aid kit has all the required elements. Resident & Staff Files : Records will be kept off location and stored at an office used as Licensee headquarters. Pool/Jacuzzi: No bodies of water were observed. Fire Extinguisher: All fire extinguishers observed are fully charged. Reading Material, Games, Equipment & Materials: The facility will have an Activities Director and bingo and other board games will be provided. Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 03/02/2023. Special conditions noted “5 approved non-ambulatory bedrooms and 1 approved staff bedroom between kitchen & living room.” Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements. Bedrooms Staff: One bedroom will be occupied by staff. Bathrooms: All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 111.9 degrees Fahrenheit. Linens & Hygiene Supplies: A supply of extra linen was stored in the hallway closet. Emergency Phone Numbers, Exit Plan & Menu: Posted and available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was posted and visible. Food Service: There is a supply of 2-day perishable and 7-day of non-perishable food on hand. Smoke Detectors: Smoke detectors and carbon monoxide detectors tested operational. Appliances: Gas five burner stove with 1 oven, 1 refrigerator, 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.