Pre-licensing visit·March 22, 2023

Licensing Program Analyst (LPA) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Applicant (AP) Nickolas Lacson, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 01/20/2023. This is a change of ownership with persons in care. During the inspection, LPA and AP observed the following: Structure. This is a two-story home. Facility is a 10-bedroom, 4-bathroom, 2 story house with detached garage that is being used for storage. There is a back yard with a patio cover for the residents. Facility telephone number is (949) 722-1014. Resident Bedrooms. The 8 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Lamps, chairs, linens, and storage for each resident bedroom inspected. Staff Bedrooms. The 2 staff bedroom are spacious and will easily accommodate the staff’s furnishings. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 118.4 and 119.8 F degrees. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. 2 days perishable and 7 days nonperishable food supply reviewed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen drawer. Toxins: observed locked in the garage and under the kitchen sink. Medication cabinet is locked. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files. LPA reviewed 3 resident and 3 staff files. Fire clearance was approved by City of Costa Mesa Fire Prevention Inspector Ben Castillo on 02/23/2023. Backyard. Backyard exit gate is operational and unlocked. Backyard has shaded area for outdoor activities and sufficient seating for residents. Component III was completed with AP during today’s inspection. Facility is currently operating under the liability insurance of current facility CROSS CREEK COTTAGE (306000888). AP will switch liability insurance to new facility once the application is approved. During the inspection, AP stated that the facility currently handles the money for 2 residents. LPA reviewed AP’s application which states that the facility will not handle resident money and that the applicant does not have a surety bond. AP agreed to either stop handling resident money or obtain a surety bond and ensure their application meets all requirements for a facility that handles resident money. AP will contact LPA by 04/05/2023 to schedule a second inspection to complete the pre-licensing inspection. During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AP was informed the items listed above must be completed for the facility to meet Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to AP.