Pre-licensing visit·June 19, 2024

Licensing Program Analyst (LPA), Zabel Chochian conducted a pre-licensing visit to this property on today and met with Victor and Martha Heredia, Owner/operators. Upon arrival LPA and applicant reviewed the application and discussed the plan of operation. Applicant acknowledged understanding the importance of operating according to the regulations and laws applicable for licensure. The applicants have obtained fire clearance for two non-ambulatory rooms (one shared and one private room) located on the first floor of the facility (total capacity of three(3) non-ambulatory residents). The Fire Clearance was approved on 05/01/2024. Component III Orientation was completed during today's visit. The property is a two-story home which consists of two bedrooms on the first floor; on the second floor there is one bedroom, bathroom and a private studio with a bathroom which operators are renting out. Private studio entrance is from the backyard. LPA informed operators that the individual renting the studio needs to be fingerprint cleared prior to issuance of the license. Operator acknowledged understanding. LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. At approximately 11am, all hard-wired smoke alarms and carbon monoxide detectors were tested and function properly. There are two bedrooms on the first floor (designated for residents) and one bedroom upstairs for the operators/staff. Each resident bedroom is equipped with clean mattresses, pillows, and bedding. There is sufficient supply of linens, including blankets, bath towels and wash cloths. Bedrooms have sufficient lighting. The facility has one (1) bathroom for resident use. Resident bathroom did not have appropriate non-skid mat and grab bars in the shower. Bathroom observed with sufficient paper products. Kitchen - Appliances and all equipment appear to be clean and in good repair. There were no locked drawers for the knives and cleaning supplies. Mr. Heredia agreed to install locks on the cabinet. The kitchen has a sufficient supply of food items, plates, cups, cook ware and utensils. The living/dining area observed clean, however not properly furnished for residents use. Mr. Heredia agreed to rearrange sufficient common living area/space for activities and lounging area for residents use. All window screens and coverings are in good repair. Enough seating for three (3) residents at the same time at the dining room table. (Cont. to LIC809C) There are activity supplies for future residents. Night-lights were present in the bathroom. Medications will be stored in a locked office cabinet. Facility records will also be stored and locked in the office cabinet. All exit doors need an alert system. Garage: The garage is attached to the house and will be locked at all times. The laundry room is inside the garage. Detergents, disinfectants, and cleaning supplies shall be stored and inaccessible. There will be no firearms/ammunition stored on the property. The exterior passageways and exits were clean and clear of any obstructions. Pool is gated and inaccessible. Backyard space for residents use which is furnished with patio chairs and umbrella for shade. Applicant was informed of the following corrections needed: 1) Proof of door alarm installation and confirm that it is working (submit photo and self certification letter). 2) Arrange living/dining/activity area for residents use (submit photo). 3) Install lock on kitchen cabinet and drawer (submit photo). 4) Tenant fingerprint clearance and copy of ID. 5) Complete first aid kit and fire extinguisher with purchase receipt (submit photo). 6) Install telephone (submit installation records and land line telephone number). 7) Install grab bar in resident shower; also obtain shower mat (submit photo). 8) Chairs and dresser for shared room (submit photo). 9) Review Plan of operation and submit self-certification letter when completed. 10) Required postings, including emergency exit plan, Licensing Complaint Poster, Long Term Care Ombudsman poster, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights. (Submit photo) This report will be sent to the Centralized Application Bureau (CAB). Once the corrections are cleared you will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted. Copy of the report provided.