Pre-licensing visit·July 5, 2023

Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 10:00 AM, LPA met with Licensee/Administrator Aileen Parel. 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 12/21/22 for a total capacity of six (6) non-ambulatory and zero (0) bedridden residents. Fire clearance was granted on 12/8/22. LPA Delgado observed the following: Structure: Facility was a one-story house with three (3) resident bedrooms, one (1) caregiver bedroom, two (2) resident bathrooms, living room, dining area and kitchen. There was an attached two (2) 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, #2, #3 will accommodate any non-ambulatory residents. Three (3) resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. Bedroom #3 was not setup for two residents and Bedroom #4 was not set up for a resident room as displayed in sketch. (CONTINUED ON LIC 809C) (CONTINUED FROM 809) Bathrooms: The two (2) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 11:20 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 125. degrees Fahrenheit. Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked cabinet 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. Washer and dryer was located inside the garage. Laundry detergents and cleaning supplies were observed a locked cabinet inside the garage away from residents. Living/Family room: There was a living room with 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. Hygiene supplies in garage Yards/Outside: Patio table and seating were observed in the backyard with gazebo for shade. There was a gate on the South side of the property with a self-latching. All outdoor pathways were free of obstructions. There is tiered waterfall decor with flowing water enclosed in a 2 feet tall cement squared wall that does not accumulate water. Emergency Phone Numbers, and Exit Plan: Facility sketch were observed posted in the front. Obudsman poster observed and PUB 475 poster not observed. (CONTINUED ON 809C) (CONTINUED FROM 809C) General items: One (1) fire extinguisher were charged and located in the kitchen; tag missing. Eight (8) smoke alarms and one (1) carbon monoxide detectors were tested and were observed to be in working order. Client records will be stored in a locked cabinet in the Dining area. 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 supply and food was observed inside the garage. Component III was completed on June 6, 2023 by facility representative Anthony Gonzales. Pre-Licensing is incomplete and the following corrections to be resolved by 7/26/2023: Fire extinguisher missing tag Hand washing signage for sink areas audible signal for resident rooms on exterior doors that lead outside warning notice for water temperature reaching more than 125 degrees Fahrenheit Posting Non-discrimination notice Posting PUB 475 obtain First Aide Manual latest edition Licensee will contact CAB Analyst to change capacity and changes to the sketch An exit interview was conducted, and a copy of this report was given.