Pre-licensing visit·July 9, 2021

Licensing Program Analysts (LPAs) Karina Canela and Jill Nakagawa conducted a pre-licensing inspection on 07/09/2021. LPAs met with Applicants Samuel and Imelda Padama, who will be the Administrator when the facility is approved for licensure. The facility has a dementia care plan and has submitted a hospice waiver request for 2 residents. The facility has a fire clearance approval from the Fairfield Fire Department for 6 ambulatory residents for a total capacity of 6. Applicant stated they will request an updated fire clearance for 6 non-ambulatory residents. Facility will operate with a 24 hour staffing and Licensee will ensure sufficient staffing at all times. During today’s visit LPAs observed the following items: · COVID-19 postings and screening station at entrance · Lockable separate cabinets for medications, toxin, and knives. · All exits were unobstructed · 7 smoke detectors, 1 combination smoke and carbon monoxide detector and 1 carbon monoxide detector, which were tested and observed to be operational · First Aid kit, night-lights, and flashlights for emergency lighting · Supply of linens, paper products, and hygiene supplies available · Grab bars and non-slip mats in 2 of 2 bathrooms. · Fire Extinguisher charged · Required furnishings in 2 of 6 resident bedrooms · A shed in the backyard used for storage · Administrator Certifications; Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, Client personal rights and visitor policy). Report continued on LIC 809-C. During today’s visit LPAs observed the following items: · Chest of drawer needed in bedrooms 3, 4, 5, and 6. Applicant stated they would purchase 4 chest of drawers a minimum of 8 cubic feet per regulation and would send pictures as proof to LPA. · 1 charged fire extinguisher without a service tag. Applicant stated it was a new purchase and would send a copy of the receipt. Pre-licensing is incomplete with corrections needed for the following items to proceed with licensure. · Required furnishings · Receipt for purchase of new fire extinguisher The Component III Orientation was completed during today's inspection. Pre-Licensing is incomplete with above items to be resolved by 7/12/2021. Applicant to submit pictures as proof of correction to Community Care Licensing Department (CCLD) for review. Once corrections are submitted and reviewed by CCLD, LPA will submit the pre-licensing report with proof of corrections to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.