Pre-licensing visit·June 13, 2025

At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert Frank arrived for a scheduled visit to conduct a pre-licensing inspection and was greeted by Licensee/Applicant/Administrator, Jonathan Luke Ensign. This pre-licensing inspection is being conducted for an initial licensing of a Residential Care Facility for the Elderly (RCFE). Fire Clearance has been approved for fifteen (15) non-ambulatory residents. All bedrooms are approved for non-ambulatory use. Applicant was not approved for bedridden residents by the local fire department. Facility has a dementia care plan. At approximately 9:10 AM, LPA initiated a tour of the facility and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. Applicant had non-slip mats and grab bars in place. LPA observed a supply of clean linens, hygiene products, and paper products available for residents. Residents' bedrooms have all the appropriate furnishings as outlined in Title 22 regulations. LPA observed dishes and cooking supplies for resident use with sharps and other hazardous items kept secured in various designated drawers and cabinets as well as under the kitchen sink. Cabinets in communal areas of the facility containing cleaning supplies and other items that could pose a risk were observed locked. Applicant agrees to keep magnets and keys to these locked areas in facility safe secured and inaccessible to residents in care. Licensee agrees to maintain at least two days of perishable foods and and one week of non-perishable foods and an emergency water supply. The required posters were observed hanging in the facility Dining area and licensee/applicant has purchased a long-term care ombudsman poster which will be hung on the wall prior to resident occupancy. Continued on 809-C... Applicant was advised to post a copy of their admissions agreement and emergency disaster plan in common area of the facility. The facility currently has the Applicant associated to facility in Guardian and will hire an additional staff members once license is approved. Applicant has been informed of association and staff transfer process. Applicant will provide an ipad/computer for residents to use. Facility currently has a cell phone as the facility phone. Applicant is going to add a land line prior to resident occupancy Facility has a designated locked cabinet for centrally stored medications. LPA observed a first aid kit and other emergency supplies. LPA recommended that Applicant add additional, age appropriate activities for elderly residents. Facility has multiple fire extinguishers, which are brand new and fully charged. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility fire alarm and sprinkler system were certified operational as of 2/21/2025. The backyard features a shaded patio area for resident use. Windows, screens, and blinds were all observed in good repair. Applicant will submit proof of liability insurance once facility has been licensed . LPA observed a facility sketch which accurately reflects the floor plan. Prior to admitting residents, applicant will: remove construction items from driveway; provide locked cabinet for resident and staff records; purchase night lights for hallways; provide curtains and or window shades for bedrooms and add a gate to step down area next to ramp near kitchen. LPA and Licensee discussed the following items: ·Hospice Waiver - Applicant to apply for a waiver if it's decided they want hospice care in the facility. Requirements for a Hospice Waiver and a Hospice instruction along with copies of 87632 Hospice Care Waiver & 87633 Hospice Care of Terminally Ill Residents regulation were provided to Licensee applicant. Guardian background clearances and associations Updated Dementia regulations Component III orientation was conducted at facility with Jonathan Ensign. Continued on 809-C2... ...Continued from 809-C Jonathan Ensign’s Administrator Certification 6069070740 is current with an expiration date of 5/7/2027. No Deficiencies or Advisories given during visit. Pre-Licensing completed. Facility is ready to be Licensed as a Residential Facility for the Elderly (RCFE). LPA will submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicant of Status. Exit interview conducted. Copy of report discussed and provided to Applicant/Administrator Ensign. Signature on form confirms receipt of document.