Pre-licensing visit·June 2, 2025

Licensing Program Analyst (LPA) LaVette Farlow, arrived at Green Willow Home Care, to conduct an announced Pre-Licensing visit for a change of ownership and change of facility name to Moonstone Care Home. LPA was greeted by Licensee Arminda B. Lopez. LPA introduced self and stated purpose of the visit. Moonstone application was submitted on 09/04/2024 for 6 RCFE, Non-Ambulatory clients. Fire Safety Inspection clearance was granted for 5 Non-Ambulatory clients and 1 Bedridden. LPA toured the facility inside and outside and observed the following: Structure: Facility is a one story house with five client bedrooms, one staff bedroom, two bathrooms, living room, family room, dining area, kitchen, pantry, laundry area, backyard and an attached two car garage. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house. Bedrooms: All bedrooms have the required bedding and furniture, such as, clean mattresses/linen, night stands, dressers, chairs, and lighting. Per facility sketch it states that bedroom #6 and bed #2 is for bedridden residents, which is currently unoccupied. Bathrooms: The client bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. The bathroom water temperature was measured 119.5, which is in regulation. (See LIC809C) Common Sitting Areas : There is adequate seating in the common areas. The facility has a supply of activities for the residents. During LPA tour of the facility, LPA observed resident watching an exercise video with staff assisting and encouraging residents to participate. Kitchen/Laundry Room/ Garage : There was a locked and secured location where medication, sharps, chemicals and residents/staff files are stored. There was non-perishable food in the pantry and perishable food in the refrigerator. The water temperature was measured at 113.8 degrees Fahrenheit. The laundry machines is in a common area in the kitchen next to an exit to the backyard. The garage has an emergency supply of food, water, and hygiene items. Chemicals, laundry soap and toiletries were safely locked. Backyard : There is covered patio, furniture and chairs in the backyard for residents to sit. There are two side gate with self-latching handle on the left and right side of the house that leads into the backyard and no bodies of water. All passageways were free from obstruction. Fire extinguisher, carbon monoxide, firearms : There is one charged fire extinguisher in the facility. LPA observed operating smoke detectors and carbon monoxide alarms. The home does not have any firearms and ammunition. Postings/ Facility Records: LPA observed required postings including the CCL complaint poster, emergency disaster plan, and facility sketch. LPA reviewed three (3) out of three (3) residents files for Physicians report, Admission agreement, Appraisal needs and service plan, and MARS. After careful review of records LPA observed that the file were free of discrepancies. LPA reviewed three (3) out of three (3) staff files. LPA reviewed staff files for the following records: Health Screening Reports, TB clearance, Personal Records, and background clearance. LPA observed files to be free of discrepancies. First aid and telephone: The facility was equipped with a complete first aid kit. The facility has a functioning land line and telephone for clients use. Pre-Licensing is complete and Comp III are complete and ready for licensure. An exit interview was conducted, and this report LIC809 and LIC809C was discussed and provided to Licensee Arminda B. Lopez.