Pre-licensing visit·June 21, 2023

Licensing Program Analyst (LPA) Elsie Campos arrived at the facility announced at approximately 9:40 a.m. to conduct a pre-licensing inspection. The LPA met with applicant Karen Rosales. This is a new facility application for (6) six residents’, rooms are cleared (6) six non-ambulatory residents at this time. The fire clearance was granted on 2/23/2023. Component III was waived as the applicant currently operates (5) five other Residential Care Facilities for the Elderly (RCFE)’s that are currently in good standing. Applicant has attended Component III in the past and is RCFE administrator certified. At 10:05 p.m., the LPA toured the physical plant areas inside and outside with applicant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN : Kitchen knives are stored locked and inaccessible in a kitchen cabinet on the left-hand side of the kitchen sink. The supply of perishable and nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and appeared functional. There is an adequate supply of emergency food and water. The Administrator was advised to use a lock with key or magnetic lock rather than a child proof locking device for the sharps, medications and chemicals as those could potentially be opened without a the use of a key. BEDROOMS : There are (6) six bedrooms in the facility; the facility has (4) four private bedrooms for resident use, (1) shared bedroom for resident use and (1) one staff room. The staff room is kept locked. All resident rooms have direct access to the outside. Lighting in the rooms appeared adequate. (3) three out of (5) five resident rooms and (1) staff room were set up with beds, night stands, lamps, chests of drawers, chairs and closet space. Administrator indicated they would be furnishing the additional rooms immediately. BATHROOMS : There are (2) two full bathrooms and (1) one half bath for resident use; the half bathroom near the entrance of the main hallway at the entrance of the home is designated for and guests. Staff have a private staff bathroom located next to the Staff room. The (1) one of (2) resident showers are equipped with nonskid surfaces and available nonskid mats. ** Continued on LIC 809-C** PAGE 2 Administrator indicated they would supply the non-skid mat for one bathroom. Grab bars were observed in the bathrooms. Hot water temperature measured in bathrooms measured between 120.3 – 121.8 degrees Fahrenheit. Administrator will adjust the hot water temperature slightly to meet regulation requirements. COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate however, various light bulbs throughout the common areas were observed to be out. There is a television and other entertainment equipment in the living room area. The facility smoke alarm system is hard wired; the smoke detectors were operable at the time of the visit. There are two (2) fire extinguishers which were fully charged and last purchased on 6/20/2023. There is a functioning telephone on the premises. Emergency exiting plans/sketch are posted. Emergency telephone numbers are posted in hallway bulletin board. Other required postings are also posted in the main hallway bulletin board. However, CCLD and Ombudsman poster were missing and the Administrator was notified and will request posters from designated agencies. MEDICATIONS : Medications are in a locked cabinet in the kitchen to the left upon entry from the main home entrance. The first aid supplies were complete, including a first aid manual. They were stored in the medication cabinet. FILES: Resident and staff records are stored in the medication cabinet in the kitchen to the left upon entry from the main home entrance. LAUNDRY : The laundry area is behind the kitchen area, directly across from the designated staff room. Laundry detergent and chemicals are stored inaccessible in a large cabinet to the right of the washer and dryer. **Continued on LIC 809-C** PAGE 3 EXTERIOR : The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs for resident use. There are no bodies of water noted on the premises. There is a gated gardening area to the back of the yard. There is a storage unit in the backyard used for miscellaneous items that is locked and inaccessible. The back and sides of the house are separated from the front yard by gates at the north and south side passageways, the gate located on the north side of the house has a self-latching door, the south side is not an exit and has no access. There is no front yard gate or driveway gate. The garage on the property is attached to the house but does not have direct access from the inside of the home and can only be accessed through the outside. The garage is used for additional storage space. There are no other structures on the property. INFECTION CONTROL: The facility has an area that will be used as a central entry point for symptom screening and sanitation station for staff, residents, and visitors. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. Facility is not compliance with Title 22 Regulations at this time. Applicant will be required to complete the following corrections and submit documentation to LPA Elsie Campos within 10 days: - Documentation of water temperatures meeting Title 22 regulations. - Documentation that all light bulbs have been inspected and replaced - Photos that rooms have been fully furnished and Photos of Ombudsman and CCLD poster posted. Skid mat has been purchased. - Photos that kitchen sharps cabinet, medication cabinet and chemicals cabinet have had the locks replaced to use a lock and key or magnetic locking device. Upon receipt of the above items, physical plant will be in compliance with Title 22 regulations. This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate under the new license number until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license. Exit interview conducted and report issued.