Pre-licensing visit·December 9, 2021

Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation for Change of Ownership. At approximately 9:30 AM, LPA met with Administrator Rosario Villanueva. An initial application to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 10/25/21 for a total capacity of six, (5) non-ambulatory and one (1) bedridden residents. Fire clearance was granted on 11/2/2021. LPA Delgado observed the following: Structure: Facility was a one-story house with six (6) resident bedrooms, four (4) resident bathrooms, living room, dining area and kitchen. There was an attached two car 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 #1, #2, #3 and # 5 will accommodate any non-ambulatory resident, bedroom #4 will accommodate bedridden resident. 5 resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. Bathrooms: The (4) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 10:20 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured between 103.2 to 104.8 degrees Fahrenheit. Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition. (CONTINUED ON LIC 809C) (CONTINUED FROM LIC 809) and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located near the bedrooms. Laundry detergents and cleaning supplies were observed in laundry room secured in a locked cabinet away from residents. Living/Family room: There was a living/family room with adequate seating for all clients and TV. Linens and Hygiene Supplies: An adequate supply of linens was stored in a cabinet in the main hallway of the residence. Yards/Outside: There is no Patio furniture for outdoor seating. There was a gate on the right side side and left side of the property with a self-latching from the exterior doors. There is debris in the backyard that needs to be cleared out. Emergency Phone Numbers, and Exit Plan: Facility sketch were observed posted in the dining room and each resident bedroom. General items: One (1) fire extinguishers were charged and located in the kitchen. Eight (8) smoke alarms with carbon monoxide detectors were tested and were observed to be in working order. Client records will need to be stored in a locked area. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply and required 72-hour emergency food supply was not sufficient. Component III was completed on this day as well. (CONTINUED ON LIC809-C) Pre-Licensing is incomplete and the following corrections to be resolved by 12/23/2021: obtain separate 72-hour emergency food supply obtain separate emergency water obtain and post visiting policy obtain 30-Days of PPE supplies obtain locks for cabinet in kitchen obtain a locked filing cabinet for clients records obtain holders for paper towel obtain patio furniture with seating for 6 residents obtain lidded trash cans for bedrooms and client bathrooms obtain and verify water temperature by a licensed plumber obtain audible alarms for clients bedrooms for doors that exit into the backyard remove debris in the backyard follow guidelines by CCLD for facility staff for COVID screening protocols update visitor sign in sheets with COVID infection control guidelines An exit interview was conducted, and a copy of this report was given.