Pre-licensing visit·May 17, 2021

Licensing Program Analysts (LPAs) Tricia Danielson and Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 1:50PM, LPAs met with Licensee/Administrator Yazmin Cerda. An initial application to operate a Residential Care For the Elderly (RCFE) facility was received by the Central Applications Unit (CAU) on 04/1/21 for a total capacity of six (6) non-ambulatory residents, one (1) of which may be bedridden. Fire Clearance was granted on 03/15/2021 for five (5) non-ambulatory residents and one (1) bedridden resident, totaling six (6) non-ambulatory residents. During today's visit, LPAs Danielson and Delgado observed the following: Structure: Facility was a single story house with five (5) resident bedrooms, three (3) resident bathrooms, living room, family room, dining area and kitchen. There was an attached garage in the front of the house. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house. Bedrooms: Each resident bedroom will accommodate any non-ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm/carbon monoxide detector. Bathrooms: All three (3) resident bathrooms have a working toilet, wash bash and an adequate supply of paper towels, toilet paper, and soap. LPAs verified bathroom water temperatures were measured at 105.0 and 107.4 degrees Fahrenheit. LPA observed toiletries for each resident and were free from commingling. (CONTINUED ON LIC 812C) (CONTINUED FROM LIC 812) Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies were secured in the locked laundry room. Knives/sharp instruments were secured in a locked closet. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all residents. Living/Family room: There was a living room with safe and adequate seating for all residents as well as working TV. Linens and Hygiene Supplies: An adequate supply of additional linens and hygiene/medical supplies were stored in a hallway cabinets and the garage. Yards/Outside: There was a patio with adequate covered seating for all residents. All walkways were observed to be free of obstructions. Garage: Garage was free of obstructions. An additional refrigerator/freezer was observed for additional food storage. Emergency Phone Numbers, and Exit Plan: Let-Us-No poster, emergency phone numbers, emergency exit plan, resident Personal Rights, and facility visitation policy were posted as required. General items: Two (2) fire extinguishers were charged and located in the laundry room and dining room. Smoke alarms and carbon monoxide detectors were in working order. Emergency lighting was observed throughout the facility. Resident records were stored in a locked closet. First Aid kit with required components, and locked area for medication storage was observed. LPAs observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Component III was completed at Licensee's additional facilities in 2016 and 2020. There are no deficiencies noted. Licensure will be granted based on final approved from CAU. An exit interview was conducted and a copy of this report was provided.