Pre-licensing visit·July 8, 2021

Licensing Program Analysts (LPAs) Martha Guzman Chavez and Brian Balisi conducted an announced Pre-licensing visit to the above facility. LPAs met with Administrator Marebeth Mallare as this is a change of ownership application from Weiss RCFE-Thousand Oaks #565801320 to Blessed Homecare, Inc. #565850160. Entrance interview conducted. Between 9:32am – 12:26pm LPAs Guzman Chavez and Balisi toured the physical plant conducted by Administrator Marebeth Mallare. LPAs inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. LPAs also reviewed resident records, staff records, medications, and medication records The following was noted: Facility is a single-story residence and consists of a total of six (6) bedrooms and three (3) bathrooms. There are four (4) bedrooms and two (2) bathrooms designated for resident use and two (2) rooms and one (1) bathroom designated for staff use. Bedrooms #4 and Bedroom #1 are currently vacant. Fire clearance was approved on 6/15/2021 for five (5) non-ambulatory residents and one (1) bedridden. Room #1 is designated for double occupancy and remaining resident rooms are cleared for single occupancy. Facility currently has two (2) residents with dementia. Smoke detectors and Carbon Monoxide detector were tested and functioned properly during time of visit. Fire extinguishers were observed to be fully charged from 6/07/2021. During physical plant tour LPAs observed the required postings throughout the facility. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPAs observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects are stored in a drawer in the kitchen to the right of the refrigerator. Continued on LIC809c Continued from LIC 809 Bedrooms: The resident bedrooms were properly furnished with a bed, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Bathrooms: LPAs observed all bathrooms were clean, properly supplied and had functional fixtures. LPAs observed all bathrooms to have grab bars and non-skid mats. The hot water was measured in each bathroom during physical plant tour and was within the required range of 105-120 degrees Fahrenheit. Bathroom #1 measured at 117.9 degrees Fahrenheit and Bathroom #2 measured at 117.3 degrees Fahrenheit. Common Areas : These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Medication are stored in a locked cabinet in the living area. Above the medication cabinet was a First-Aid Kit that was complete. Outdoor Area: There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises. There are two (2) fence gates that self-latch with clear passageways for emergency exit use. Comp III was completed in conjunction with the visit. Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. A copy of this report will be forwarded to the application specialist with LPA's recommendation for licensure. An exit interview was conducted with Administrator, and a hard copy was provided via email.