Pre-licensing visit·December 5, 2025

Licensing Program Analyst (LPA) Cuadra arrived announced to conduct a pre-licensing inspection and was greeted by Applicant, Hanz Palma and Amy Villasan. Facility currently does not have residents in care. Once obtained, Applicant will submit proof of required liability insurance. The facility has submitted a dementia care plan. Hospice waiver for two residents. The facility consists of a single story residence with a total of five bedrooms, One shared bedroom (room #2 & # 6), two full bathrooms, staff room, laundry area located in the hallway, kitchen, dining room, living room as common areas an outside sitting & garden area available for resident use . Lock storage shed located at the back of the facility. Applicant lives on the premises in a detached unit located in the back of the facility. LPA explained that every individual who could reside at this detached unit needs to be fingerprinted prior to live, work or volunteer at the home. The facility received a fire clearance approval on 9/10/2025 by the City of Fairfield Fire Department for total capacity of six (6) residents which four (4) may be non-ambulatory residents in rooms 2 (shared), 4 and 5 and two (2) are ambulatory residents in rooms 1 and 3, which none may be bedridden nor is approved of delayed egress devices. Administrator certificate for administrator Hanz Palma #6079330740 expires on 9/24/2027. Contact information reviewed. LPA observed all required postings including the CCL Complaint Poster, Long Term Care Ombudsman Poster, Resident's Rights, and the rights to Resident and Family Councils. Continues on LIC809C... Continued from LIC809... At approximately 9:45am LPA/Applicant toured the building and grounds. The facility was found to be consistent with facility sketch, and at a comfortable temperature. Indoor and outdoor passageways are free of obstructions and is enough to permit residents with a diagnosis of dementia wander freely and safely. Window screens are clean and in good repair. All resident rooms are furnished per regulation with bed, lamp, bedside table, dressers and chairs. Garage houses gardening tools storage, incontinence care supplies and emergency supply of water. Cleaning supplies will be stored in a cabinet located in the garage, and locked cabinets located under kitchen sink and laundry area. Sufficient supply of linens and hygiene products observed. Kitchen cabinet has locks installed for knives to be inaccessible to residents in care. Locked centralized medication cabinet is located in the kitchen including first aid kit. First aid kit present with all required items. Garbage cans have tight fitting covers, there are sufficient amount of dishes, utensils, cooking pots, etc. Office has locked door and cabinet with a lock that will be used for confidential file storage of personnel and residents records. Back yard is connecting to shared bedroom #2 & 6, bedroom # 4 and 5 allowing access to the backyard, and they have auditory alarms installed at the doors that were tested and operational during the visit. Emergency lighting and flashlights available. Each room has an alert pendant that it was found operational. Water temperatures read at: 105.1 and 105.6 degrees F which is within 105-120 F degrees regulation. All bathrooms have grab bars and skid mats available. Smoke and carbon monoxide detectors present and functioning. Two fire extinguishers serviced on September 2025. Night lights in hallway are present. Activity calendar and supplies as well as sample of menu was observed. The Applicant agreed that they need to include the use of surveillance cameras in common areas to their admission agreement to make residents and their responsible parties aware of their use without audio. Applicant has satisfied all requirements in accordance with Title 22 Regulations including Component III. LPA will notify Application Unit Pre-licensing inspection is complete to proceed with the process of license. Pre-Licensing is now complete. Exit interview conducted with Applicants and a copy of this report was given.