Pre-licensing visit·April 7, 2025

On 4/7/2025 at 09:30 AM, Licensing Program Analysts (LPA) Eldin Serrano conducted an announced visit to the facility for purpose of Prelicensing evaluation. LPA met with Applicant Carina Davis. An initial application to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 10/15/2024 for a total capacity of six (6) nonambulatory, of which two (2) maybe bedridden and waiver/granted for hospice care for six (6). Fire clearance was granted on 2/5/2025 for six (6) non-ambulatory residents and two (2) bedridden. LPA Serrano observed the following: Structure: Facility was a one (1) story house with five (5) resident bedrooms, and two and half (2.5) bathrooms, living room, dining area/kitchen and laundry. There was an attached two (2) car garage in the left side of the house. Heating/Cooling System: Central heating and air conditioning system installed with one (1) central panel located in the hallway to control entire house. Bedrooms: Each resident bedrooms accommodate any nonambulatory residents and bedroom #2,#3,#4 is for bedridden resident. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, nightstands, a lamp and an operable smoke/carbon monoxide alarm. ***CONTINUED ON LIC 809-C*** Bathrooms: The two and half (2) resident/staff bathrooms have a working toilet, wash basin, grab bars, non-slip mat and shower with an adequate supply of toilet paper and soap. LPA Serrano tested the water temperatures in the residents' bathrooms. LPA Serrano verified water temperature was measured at 111.9 degrees Fahrenheit. Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments were secured in a locked closet in the hallway. There was adequate room for food storage. LPA Serrano observed the stove to be operational. Refrigerator/freezer were in working condition. There is sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was in the laundry room. Laundry detergents and cleaning supplies were observed in a locked cabinet. Garage door is locked away from residents. Living Room: There was a living/family room with adequate seating for all clients and a working TV. Linens and Hygiene Supplies: An adequate supply of linens was stored in a cabinet in the hallway of the residence. Yards/Outside: Patio furniture for outdoor seating observed. Self-latching handle gate on left side of the house that leads into the backyard. All outdoor pathways were free of obstructions. Emergency Phone Numbers, and Exit Plan: Facility sketch was observed posted near the main entrance. Emergency/Disaster plan posted by the entrance. There was Let-Us-Know poster. . Dementia Care Plan: LPA Serrano observed and reviewed the Dementia Care Plan during the visit. ***CONTINUED ON LIC 809-C*** General items: Two (2) fire extinguishers were charged and located in the hallway and kitchen. Seven (7) combined smoke detectors and carbon monoxide detectors were tested and were observed to be in working order. Resident records and staff records will be stored in a locked cabinet in the hallway. First Aid kit with required components, First Aid Book and locked area for medication storage was observed. LPA observed a facility phone and was operational as evidenced by LPA dialing the number. The phone number designated for the facility is 909-570-9139. There is enough Emergency water supply and the required 72-hour emergency food supply for residents and staffs available at the facility. Component III was completed on this day as well. Additionally, LPA Serrano observed facility having Visitor Sign In/Sign Out Sheet and Client Sign In/Sign Out Sheet, upon entering facility. The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22, Division 6, Chapters 1 and 6 to ensure the health and safety of clients in care. Facility appears to be ready for licensure. An exit interview was conducted, and a copy of this report, LIC809 was discussed and provided to Applicant Carina Davis .