Pre-licensing visit·January 3, 2025

Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with designated Administrator (AD) Thomas Adams. An application to operate a Residential Care Facility for the elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden residents was received by CCL on September 25, 2024. Structure: The facility is a one-story house with three resident bedrooms, one staff bedroom, two bathrooms, a living room, a kitchen, a dining room, a family room, a laundry room, and attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entranceway. There is a backyard with an exit gate each side of the house. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard. Resident Bedrooms All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets. 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 in the laundry room. 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 in a locked file cabinet. Pool/Jacuzzi: No bodies of water were observed. Fire Extinguisher: Fire extinguisher is fully charged. Reading Material, Games, Equipment & Materials: The facility has magazines, arts and crafts supplies stored in living room and additional recreational materials for resident use will be maintained. Fire clearance: Was approved by a fire inspector of City of Placentia Fire Department on October 15, 2024. No special conditions noted. Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements. Bedrooms Staff: There is one staff bedroom. Bathrooms: All bathrooms have working plumbing. Hot water measured between 114.9- and 115.3-degrees Fahrenheit. Linens & Hygiene Supplies: A supply of extra linen was stored in the hallway storage closet. Emergency Phone Numbers, Exit Plan & Menu: Posted and available, means of exiting, and emergency phone numbers. Food menu is also posted and available. Food Service: A supply of 2-day perishable and 7-day of non-perishable food was observed and will be maintained on hand. Smoke Detectors: Smoke detectors and carbon monoxide detectors tested operational. Appliances: Gas burner stove, refrigerator, 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. An exit interview was conducted and a copy of this report was provided to Licensee.