Facility Evaluation Report

Licensing Program Analyst (LPA) Jose Villalobos conducted an announced pre-licensing visit and met with Applicant Hyo Sook (Monica) Kim. The purpose of the visit was discussed.

An application for an Initial License was submitted to the department on 9/13/23. The facility will operate as a Residential Care Facility for the Elderly (RCFE). The facility has a total capacity to serve up to six (6) Residents. Fire clearance approved for six (6) residents who may be non-ambulatory, of which up to three (3) may be bedridden. Fire clearance for bedridden residents may be in Rooms #2-#4. Hospice Waiver approved for up to six (6) residents in care. Dementia care plan is in place.

The facility is a single-story home: Total of (9) bedrooms of which #1-#6 is for residents only and #7-#9 are staff break rooms and office spaces, (3) bathrooms, dining room, (2) living rooms, backyard with locked detached garage, and a laundry area. The physical plant was toured.

· There is a locked storage area that is centrally located for medication.

· Cleaning supplies are kept separate from food and located in a locked cabinet.

· Facility walls, ceilings, floors, window screens and areas around the facility are clean and in good repair.

· Fire extinguishers and smoke/CO2 detectors operate properly.

· Doors and passageways are free of obstruction.

· There are no pools/bodies of water at the facility.

· Facility does not have firearms on premises.