Pre-licensing visit·June 27, 2023

Licensing Program Analysts (LPAs) Dwayne Mason Jr. and Claudia Gutierrez 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) Kathrina Buller. An application to operate a Residential Care Facility for Elderly (RCFE) for (15) capacity, (0) ambulatory, (15) non-ambulatory, and (0) bedridden clients was received by CCL on 6/2/2023. Structure: The facility is a two-story home with eight resident bedrooms, three bathrooms, living room, kitchen, dining room two staff bedrooms, staff bathroom and an attached two car garage. LPAs observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the dining room area. There is a back yard with two exit gates on each side of the house. There are five shaded seating areas in the backyard. LPAs did not observe any obstacles or hazards in the backyard. Client Bedrooms All resident bedrooms had the required furnishings. LPAs observed all resident beds had linens and blankets. LPAs observed all windows were screened. Signal system There is signal system that each of the residents will have access to via handheld device. Each device sends a signal to the signal system’s interface in the med room. This signal will let the staff know which resident needs assistance. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked beneath the kitchen sink. Medications, First-Aid Kit & Book: Medication will be stored in a locked cabinet. First aid kit is stored with the medication. The first aid kit has all the required elements. Resident & Staff Files : Records will be kept locked in storage cabinet located in the kitchen. Fire Extinguisher: All fire extinguishers are fully charged. Reading Material, Games, Equipment & Materials: The facility has activity materials that will be kept in the dining room area. Puzzles, Bingo, card games and other games will also be kept for resident use. Fire clearance: Was approved by a fire inspector of City of Costa Mesa Fire Prevention on 05/31/2023. Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements. Bedrooms Staff: Two bedrooms will be occupied by staff. Bathrooms: All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 106.3 degrees Fahrenheit. Linens & Hygiene Supplies: A supply of extra linen was stored in the hallway storage. 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.