Pre-licensing visit·January 30, 2026

Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Administrator/ Licensee Divina Alipio. An initial application to operate a Residential Care Facility for the Elderly was submitted to Community Care Licensing on 10/05/2025 for a capacity of three ambulatory and one non-ambulatory resident. Upon entry, facility appears clean, safe and sanitary. Facility has all required postings including personal rights, theft and loss policy, and the complaint poster. Administrator Divina Alipio has an administrator certificate expiring on 06/19/2026. LPA Lyman along with Administrator Alipio toured the facility at 8:19 AM and observed the following: Structure: Facility is a one story home with four bedrooms, two restrooms, living room, screened patio, dining room and kitchen and a grey exterior. Living Room/ Dining Room : Adequate seating is available in the dining room and living area. Bedrooms Residents: Rooms are single occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample storage space, Exit doors have auditory alarms. Linens & Hygiene Supplies: Facility has ample bedding and towels in supply as well as hygiene supplies. Bathrooms: All resident bathrooms have a working toilet/ wash basin/ grab bars as well as paper towels and soap. Emergency Phone Numbers and Exit Plan: Posted in the entrance of the facility. Food Service: LPA observed the kitchen and serving area. Facility has two day perishables and seven day non-perishables. LPA observed a sample menu. Smoke Detectors: Smoke detectors and carbon monoxide detectors tested operational during today's visit. Fire extinguishers are fully charged. Appliances: Kitchen and laundry appliances are clean and operational. Toxins / Sharps : Facility has secured areas for toxins and sharps. CONTINUED ON LIC 9099C DATED 01/30/2026 Water Temperature: Tested and recorded between 105.2 and 108.6 degrees F. in facility restrooms. Emergency Supplies: LPA observed ample emergency food and water as well as emergency packs for residents. LPA observed the emergency disaster plan which is thorough and complete. Medications, First-Aid Kit & Book: First aid kit observed contained all required items including tweezers, scissors and thermometer as well as a first aid manual. Medications to be stored in a locked cabinet. Facility to use a medication administration record. Resident & Staff File: Records are to be stored in a locked cabinet in the screened in porch. Reading Material, Games, and Equipment: LPA observed a posted activity schedule with activities such as games and outings in the community. Outside areas : LPA observed an outside area with ample shaded seating. Fire Clearance: Approved for three ambulatory and one non-ambulatory resident on 08/21/2025. Component III conducted during the visit. Facility is ready to be licensed. Exit interview conducted and a copy of this report was left at the facility.