Pre-licensing visit·September 4, 2025

Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 9:00 AM, LPA met with Administrator Favie Jimeno. 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 1/30/2025 for a total capacity of six (6) non-ambulatory, of which one (1) bedridden resident. Waiver/Granted for Hospice Care for two (2). Fire clearance was granted on 2/20/2025. LPA Delgado observed the following: Structure: Facility was a one-story house with four (4) resident bedrooms, three (3) resident bathrooms, living room, dining area, kitchen, office-which is used for live-in staff and one (1) staff room. There will be live-in staff on premises. 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-private non-amb, #2-shared non-amb, #3-shared non-amb and #4-private bedridden will accommodate any non-ambulatory resident, bedroom #5 will accommodate bedridden residents. Four (4) resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. Bathrooms: The three (3) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. (CONTINUED ON LIC 809C) (Continued from Page 1) At 10:46 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 121.3 degrees Fahrenheit with caution warning labels posted. 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 garage. Laundry detergents and cleaning supplies were observed in garage 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 stored in the main hallway and hygiene supplies was stored in a cabinet near the kitchen area. Yards/Outside: Patio table, chairs and covered patio were observed in the backyard. There was a gate on the West side of the property with a manual latch. All outdoor pathways were not free of obstructions. Emergency Phone Numbers, and Exit Plan: Facility sketch were observed posted in the main hallway and residents bedrooms. Obudsman poster and Let-Us-No poster observed. General items: Two (2) fire extinguishers were charged and located in the kitchen. Seven (7) dual smoke/carbon monoxide alarms 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 and food supply was observed. Component III was completed on 08/12/2025 at Riverside RO. (Continued on Page 3) (Continued from Page 2) Pre-Licensing is incomplete and the following corrections to be resolved by 9/25/2025: update floor plan per Licensee changes of office to additional staff room, email CAB analyst and cc'd LPA obtain night light for common bathrooms obtain hoyer lyft training for all staff obtain current edition for First Aid manual remove debris in the backyard repair faucet leak in bathroom #1 repair outdoor pathway leveling replace battery for sliding door alarm #2 replace exterior window screen An exit interview was conducted, and a copy of this report was given.