Facility Evaluation Report

On 12/30/24, Licensing Program Analysts (LPA) M. Yang conducted an announced Pre-licensing / Component III Inspection. LPA introduced self, stated the purpose of the visit and was allowed entry into the facility. LPA met with Assistant Administrator (AA) Diana Diaz. Licensee (L1), Jason Johnson was called and stated authorized AA to conduct inspection and signed report.

The facility is a 2 bedroom, and 2 bathroom home and fire clearance were granted for 3 non-Ambulatory in room 1 and room 2 and 1 bedridden in room 2 for a total capacity of 4. Facility telephone number is 661-381-7203.

LPA toured the facility with AA. Facility was free from ground obstructions and odor free. Common areas were observed to have adequate seating and lighting available. A fire extinguisher was observed and had a service date of 07/10/24. Kitchen was toured and observed to have dishes, plates, and utensils. Knives will be kept locked in kitchen drawer. Refrigerator temperature maintained at 40 degrees F. Cleaning supplies was observed stored and locked under kitchen sink. LPA observed 2 day perishable and 7 day nonperishable food. Medications will be locked in hall closet. First aid kit was observed and contained all required items. Bedrooms were observed to have the required furnishing and are ready for occupancy. LPA observed an extra supply of bed linens and towels. Hot water temperature ranged between 116.1 degrees F in bathroom master bathroom and 118 degrees F in bathroom. Toilet observed operational and functional during inspection. Outside of facility toured. Exits were open and free of obstructions. LPA observed side gate to be self-latching and free debris. Smoke detectors and carbon monoxide were observed to be operational during this inspection.

Component III was conducted during today's pre-licensing visit. I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.