Pre-licensing visit·July 1, 2025

Licensing Program Analyst (LPA) William Vanegas made an announced visit for the purposes of conducting the pre-licensing inspection for a change in ownership of the facility. LPA Vanegas met with previous owner Mariana Nita and new owner Stevelyn Reroma. LPA Vanegas began a tour of the facility and observed the following. Structure: This facility is a two storied home with 10 rooms 6 rooms are private resident rooms located on the first floor of the facility. There are 4 additional rooms located on the second floor, however 3 rooms are staff rooms, and 1 room is used for storage. The facility has 4 and a half bathrooms. 3 are for resident use, and and 1 is for staff and visitors. The facility also consists of an attached three car garage. LPA Vanegas observed a washer and dryer, refrigerator, microwave, and electric stove all in good repair, and tested operational. There is an outdoor shaded sitting area, and a fully fenced pool in the backyard, with the fence measuring 4ft, 3in tall, and the gaps between the fence are 4 inches. Side doors along exit rout of the facility are self latching and unlocked. Food Services: Seven day supply of non-perishable food is available for residents in care. Two day supply of perishable food was observed to be in the kitchen area, and a sufficient amount of emergency water was available for residents in care as well. Smoke and Carbon Monoxide Detectors: All carbon monoxide and smoke detectors were tested to be operational and in good repair. CONTINUED ON LIC809C Fire Extinguishers: All fire extinguishers were mounted, fully charged, and scheduled to be serviced on July 19, 2025. Fire Clearance: Approved on March 11, 2025 for 6 non-ambulatory clients. Toxins and Sharps: Cleaning supplies, toxins, and sharps were observed to be secured and inaccessible Water Temperature: The hot water temperature measured at 116.4-117.2 in the client bathrooms and 115.8-116.2 degrees Fahrenheit in the staff bathrooms. Medications, First Aid Kit, & Manual: The First Aid Kit was observed to have all required items such as adhesive tape, bandages, scissors, tweezers, and a thermometer. The manual was also available. Signal System: No signal system. Bedrooms: The client bedrooms had all required components, are spacious, and easily accommodates furnishings. Bathrooms: Bathrooms were operational and slip resistant mats were present. Facility will deep clean all bathrooms and install locks on all client bathrooms. Linens and Hygiene Supplies: Clean linens and hygiene supplies were observed to be fully stocked. CONTINUED ON LIC809C Resident and Staff Files: Client and staff records are maintained on site and available for the Department's inspection. Reading Material, Games, Equipment, & Materials: The facility maintains games and activities in the living room area and closet. Emergency Phone Numbers/Exit Plan: Posted on the bulletin board by the entry way. Postings: The See Something, Say Something (PUB475), the Rights of the Resident Councils, Resident's Rights, were posted in the entry way. A copy of the Admission Agreement is available at the facility upon request. Component III: Component three Orientation was waived with Applicant Stevelyn Reroma because of Change of Ownership, and applicant is currently working with same clients and previous owner. The pre-licensing visit is now complete. The facility meets the requirements for licensure. LPA Vanegas will forward this report to the Centralized Applications Bureau for review. The license will be granted upon completion of a final review and approval from the Centralized Applications Bureau. Exit interview was conducted and a copy of this report was left with Applicant Sevelyn Reroma.