Pre-licensing visit·October 10, 2023

Licensing Program Analyst (LPA) Cheryl Goodrich arrived at 1:14 pm. to conduct an announced pre-licensing visit. LPA met the Administrator, Amy Gladden at the front door and was granted entry. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6 and has met pre-licensing requirements to open facility. Facility is approved for six (6) non-ambulatory residents with 0 residents in care. Infection Control: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies. Physical Plant and Environmental Safety : The facility temperature read at 71 degrees. The facility consists of 4 resident bedrooms, and 4 bathrooms, living room, kitchen, and backyard. The bedrooms are furnished with tv, lighting, closet space, and dresser. The beds are clean and have clean linens and the pathways are clean and clear of obstruction. The living room and kitchen clean and clear of obstruction. The medications are stored in a locked cabinet in the locked office and inaccessible to the resident. The facility and has a current fire clearance, smoke and carbon detectors and fire extinguishers and are in working order. Personnel Records-Training: The staff records are not available at this time due to no staff being employed. Client Records-Incident Reports: The facility has a binder that will contain identification and emergency information, physician’s report, resident appraisal, IPP, client rights, and admissions agreement. The facility currently does not have any residents in care. (Continued on LIC809-C) (Continued from LIC809) Client Rights-Information: The facility has client rights information posted in the facility. Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available. Health- Related Services: The facility has a medication logs will be in the resident's files, however no records are present due to no residents in care. Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff and residents in care. The last fire drill was completed 10/09/23. The facility has emergency supply of food and water. Summary: Based on today's visit, no deficiencies were observed at this time. The facility has completed their pre-licensing requirements. An exit interview was conducted with Administrator, Amy Gladden and a copy of this report was printed Signature below confirms receipt of these rights.