Pre-licensing visit·December 2, 2025

Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 08:45 AM, LPA met with Licensee Vilma Tejada, Administrator Dolores Jara. 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 2/10/2025 for a total capacity of six (6) non-ambulatory and Zero (0) bedridden residents. Fire clearance was granted on 05/13/2025. LPA Delgado observed the following: Structure: Facility was a one-story house with five (5) resident bedrooms, two (2) resident bathrooms, living room, family room, dining area, and kitchen. There was an attached one car garage in the front of the house and office is located inside. 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, #4 and #5 will accommodate any non-ambulatory resident. Five (5) resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. Bathrooms: Two (2) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 10:10 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 106.7 degrees Fahrenheit. (CONTINUED ON LIC 809C) (Continued from LIC809, 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 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 was stored in a cabinet in the main hallway of the residence and hygiene supplies stored garage. Yards/Outside: Patio table and chairs were observed in the backyard. There was a gate on the East side and West side of the property with a self-latching hook. All outdoor pathways were free of obstructions. Emergency Phone Numbers, and Exit Plan: Facility sketch were observed posted in the main hallway and each resident room. Ombudsman poster and Let-Us-No poster observed. General items: One (1) fire extinguishers were charged and located in the kitchen. Six (6) smoke alarms and one (1) carbon monoxide detectors were tested and were observed to be in working order. Client records and Staff records are stored in a locked cabinet in the Office. First Aid kit with required components, and 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 was observed however the required 72-hour emergency food supply was not discernible from the regular food supply. Component III was completed on November 18, 2025. (CONTINUED ON PAGE 3) (Continued from LIC 809, Page 2) Pre-Licensing is incomplete and the following corrections to be resolved by 12/9/2025: obtain a separate 72-hour emergency food supply obtain night light for hallway obtain and post Non-discrimination notice obtain knob for kitchen cabinet door obtain latest edition of First Aid Manual repair exterior window screen x2 replace trash can with lid An exit interview was conducted, and a copy of this report was given.