Facility Evaluation Report

Licensing Program Analysts (LPAs) Sanjay Vaid, Luis Mora and Nune Margaryan made an announced visit and met with Licensee Flormine Resurreccion to conduct an announced Pre-Licensing evaluation.

An initial application was submitted to Community Care Licensing Department (CCLD) for an Adult Residential Facility (ARF) to serve adults between the ages of 18 - 59. The requested capacity is four (4) non-ambulatory clients of which one (1) client may be bedridden. Structure : Facility is a single-story home located in a residential area consisting of four (4) client bedrooms private bedrooms, one (1) staff room, two (2) bathrooms, kitchen, dining room, living room, laundry area located in the garage of the facility. Backyard has a covered shaded area and is currently furnished. Front yard is landscaped with grass and back yard is landscaped with cement and grass. Bedroom Clients : Bedrooms are equipped with one bed, nightstand, lamp, and overhead lighting. Bathrooms : Two (2) full bathroom equipped with working toilets, wash basins, bathtub/ walk-in shower. Water Temperature : Water temperature in the bathrooms and kitchen was tested and measured between 105 -120 degrees Fahrenheit as required. Linens & Hygiene Supplies: All beds had the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linens is stored in hallway closet. Emergency Phone Numbers, Exit Plan: Emergency numbers are posted and readily available for review. Two (2) fully charged fire extinguishers were observed. Facility has a land line telephone. Food Service : Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils were observed locked and inaccessible. Adequate food supply is stored in the kitchen and consists of the following: 2-day perishables, and 7-day non-perishables. Emergency water supply was observed. Smoke Detectors: There are electrical smoke detectors located in all bedrooms, common areas, and hallways. Appliances : Refrigerator, oven, microwave, dishwasher, and washer/dryer are in new condition. The residence is equipped with central heating and air conditioning. Toxins : Cleaning supplies, and toxins are locked only accessible to staff.

No outstanding or pending items were observed by the LPAs requiring additional pre-licensing visits. LPAs will notify the assigned Centralized Applications Bureau (CAB) Analyst of the completed pre-licensing facility evaluation visit conducted, which included the Component III Orientation.