Pre-licensing visit·May 5, 2025

Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 1:30 PM, LPA met with Licensee/Administrator Ana Marie Huerto. An initial application for Change of Ownership to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 1/8/2025 for a total capacity of six (6) one (1) non-ambulatory and five (5) bedridden residents. Fire clearance was granted on 1/23/2025. LPA Delgado observed the following: Structure: Facility was a one-story house with four (4) resident bedrooms, two and half (2.5) 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 shared bedridden, #2 private bedridden, #3 private non-ambulatory and #4 shared bedridden. Resident rooms #1, #2, and #4 designated/approved for bedridden. Three of Four (4) resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. Room #3 was not set up. Bathrooms: The two and half (2.5) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 2:11 PM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 111.3 degrees Fahrenheit. (CONTINUED ON LIC 809C) (Continued from Page 1) 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 and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the home. Laundry detergents and cleaning supplies were observed in laundry room locked and secured away from residents. Living/Family room: There was a living/family room with seating for all clients and TV. Linens and Hygiene Supplies: An adequate supply of linens and hygiene supplies was stored in a cabinet in the main hallway of the residence. Yards/Outside: Patio table and six (6) chairs were observed in the backyard. There was a gate on the South side of the property with a self-latching lock. All outdoor pathways were free of obstructions. Emergency Phone Numbers, and Exit Plan: Facility sketch were observed posted in the main hallway and each room. Obudsman poster and Let-Us-No poster observed. General items: One (1) fire extinguisher were charged and located in the kitchen. Nine (9) smoke alarms and six (6) carbon monoxide detectors were tested and were observed to be in working order. Client records will be stored in a locked cabinet in the kitchen. 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 emergency food was not sufficient. Comp III has not been scheduled. (Continued on Page 3) (From Page 2) Pre-Licensing is incomplete and the following corrections to be resolved by 6/2/2025: obtain additional 72-hour emergency food supply obtain emergency water obtain window screens set-up room #3 update sketch to include outdoor storage shed An exit interview was conducted with Ana Marie Huerto and a copy of this report was given.