Pre-licensing visit·July 10, 2025

On 7/10/2025 at 08:50 AM, Licensing Program Analyst (LPA) Eldin Serrano conducted an announced visit to the facility for purpose of Prelicensing evaluation. LPA met with Applicant/Administrator Elizabeth Colunga. An initial application to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 06/05/2024 for a total capacity of six (6) of which six (6) can be nonambulatory and two (2) hospice care waiver. Fire clearance was granted on 09/19/2024 for six (6) non-ambulatory residents. LPA Serrano observed the following: Structure: Facility was a one (1) story house with four (4) resident bedrooms and two (2) 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. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, nightstands, a lamp and an operable smoke/carbon monoxide alarm. Bathrooms: The two (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. ***CONTINUED ON LIC 809-C*** ***CONTINUED FROM LIC 809*** LPA Serrano verified water temperature was measured at 107.7 degrees Fahrenheit. 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 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 restroom of the residence. Yards/Outside: Patio furniture for outdoor seating observed. Self-latching handle gate on both 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. There was Let-Us-No poster, Ombudsman Poster. Dementia Care Plan: LPA Serrano observed and reviewed the Dementia Care Plan during the visit. General items: Three (3) fire extinguisher was charged and located in the kitchen, hallway, laundry room. eight (8) smoke detectors and two (2) 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 family room. First Aid kit with required components, First Aid Book and locked area for medication storage was observed. ***CONTINUED ON LIC 809-C*** ***CONTINUED FROM LIC 809*** LPA observed a facility phone and was operational as evidenced by LPA dialing the number. The phone number designated for the facility is 909-222-4795. 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/ Administrator Elizabeth Colunga.