Pre-licensing visit·July 23, 2024

Licensing Program Analyst (LPA) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at facility was greeted and granted entry. LPA met with Maricel Nepomuceno, applicant and Bryant So, Administrator. An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (5) capacity, (0) ambulatory, (4) non-ambulatory, and (1) bedridden resident was submitted to CCL on 12/11/23. Structure: The facility is a one story house with an attached garage with 5 resident bedrooms, 1 staff bedroom, 2 full bathrooms, 1 half bathroom a living rooms, a dining room, and a kitchen. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a back yard with exit walkways on both sides of the house with covered seating for the residents. Air/Heating: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms will accommodate 5 residents with all bedrooms being private having one resident per room. Bedrooms Staff: Bedroom #1 is designated bedroom for live-in staff. Bathrooms: Facility has 2 full bathrooms and 1 half bathroom. All bathrooms have a working toilet, wash basin, walk in shower. Linens & Hygiene Supplies: Adequate supply of linen in hallway storage. Emergency Phone Numbers, Exit Plan & Menu: Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food serve for one week. Food Service: Adequate supply of 7-day non-perishable and 2-day perishables are stored in the kitchen with extra Continued on LIC809-C food supplies stored in the spare refrigerator in the garage. Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired, were tested, and found operational. Fire extinguishers mounted in kitchen dated 2/15/24. Appliances: Gas four burner stove, single oven, 2 refrigerator (kitchen and garage), microwave, dishwasher, washer, and dryer are clean and noted to be operational. Toxins: All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are stored and locked underneath kitchen sink and garage. Water Temperature: Tested and recorded maintained at a comfortable temperature and the water temperature measures 112.4 Fahrenheit degrees in facility bathrooms. Medications, First-Aid Kit & Book: Medication and First Aid kit are stored in bedroom storage cabinets locked inaccessible to residents in care. Resident & Staff Files : Resident records will be kept locked in a locked cabinet located in the office space and staff records are kept with medication storage. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the resident's use, commensurate with the plan of operation. Fire clearance: Was approved on 06/5/24. Resident bedroom #5 approved for 1 bedridden resident. Component III: Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities. The applicant has met all pre-licensing requirements. LPA will submit notification to CAB in Sacramento for final review prior to license being issued. Exit interview was conducted with applicant and a copy of this report was left with at the facility.