Pre-licensing visit·November 3, 2021

Licensing Program Analyst (LPA), Tiffany Holmes conducted an announced Pre-Licensing visit to observe the facility's compliance with Title 22, Division 6 regulations and the California health and safety code. LPA met with Administrator, Dominque "DJ" Mase. Facility is applying to serve four (4) residents over 60 years of age. () rooms at the facility are approved for non-ambulatory use. During today's visit LPA, accompanied by Administrator DJ conducted a facility tour. LPA observed resident rooms and found them to have proper furnishings, and adequate linens. Sinks accessible to residents had running water. Facility temperature was read at 70 degrees Fahrenheit. Facility had a working fire extinguisher. Smoke and carbon monoxide alarms were observed and operational. The Fire Department granted clearance on 09/16/2021. Administrator stated that there will be no weapons or ammunition kept on the facility property. Staff and resident records will be stored in a locked cabinet. There is a shaded outdoor space and appropriate resident activities. All cleaning supplies or potentially hazardous materials were locked. Facility has a locked area for resident medications and first aid kits. Administrator Certificate expires on 12/29/2022 . Component III was reviewed with the Administrator. The application will be sent to the Centralized Application Bureau for final review and approval. An exit interview was conducted with Administrator, Dominque "DJ" Mase . A copy of this report and Licensee Appeal Rights (LIC 9058 01/16) was provided vie email. An electronic read receipt confirms receipt of these documents.