Facility Evaluation Report

Licensing Program Analyst (LPA) Jose Villalobos conducted an announced visit with applicant Iwona Kaya. Applicant Stefanie Skormorucha was present via facetime. The purpose of the visit was to conduct the Pre-Licensing for the facility listed above.

An application was submitted to CCLD on 12 /6 /2022, for a Change of Ownership of a Residential Care Facility for the Elderly for ages 60 years and older. The requested capacity of 6 residents, (0) ambulatory, (6) non-ambulatory and (0) may be bedridden and Hospice Waiver up to (4) residents.

The facility is part of a single story home located in a residential area and contains the following: living room, dining room, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, locked storage cabinet for medications and sharps, (4) resident rooms, (1) live in staff room (2) bathrooms for residents and (1) bathroom for the live in staff; bathrooms with shower, toilet and washbasin. A back yard with shaded area and seating for resident use. A connected garage inaccessible to residents for storage and Laundry; with washer and dryer. The residence is equipped with air conditioning in each room. The facility is currently operating under facility # 198602532 and has 6 residents in the facility.

Accommodations : Adequate accommodations observed throughout facility. Lighting: Sufficient Lighting throughout. Hallway and Doorways: Free and clean of obstruction and debris. Resident Rooms: Bedrooms #1-#4 are for non ambulatory residents. Bedroom #5 is used for live in staff. All bedrooms are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, and closet space, and beds for each resident. Bathrooms: Bathroo m #1, # 2 have a working toilet, wash basin, shower, grab bars and nonskid mats.