Facility Evaluation Report

Licensing Program Analysts (LPAs) Mora and Gutierrez conducted an announced Pre-Licensing visit. LPAs met with Flormine Resurreccion (Licensee) and explained the reason for the visit. An initial application was submitted to Community Care Licensing Department (CCLD) for an Adult Residential Facility to serve 4 non-ambulatory clients, of which 1 may be bedridden in the age range of 18 through 59. Hospice waiver granted for 4 clients.

The facility is in a residential area and it is a one story family home. A tour of the single-story facility included the 4 client bedrooms, 2 bathrooms, living room, dining area, kitchen, staff break room, laundry room, front yard, backyard. LPAs conducted the tour with Flormine and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps and cleaning solutions are kept locked in a kitchen cabinets. Client and staff files and medications will be locked in a dining area pantry. The First Aid kit is kept locked in the dining pantry and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in the hallway cabinets. Dining and living room have sufficient lighting and sitting area. All bedrooms have all required furniture, lighting, and bedding. All showers were observed with non-skid carpets. The water temperature was tested in both bathrooms and measured at 109 degrees F and 106.2 degrees F, which is within the required 105-120 degrees F. Fire extinguisher was observed in the kitchen and it is fully charged. Smoke detectors were observed throughout the facility and in each room and were operable during the visit. A carbon monoxide was observed in the hallway and was operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.

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.

Exit interview conducted and a copy of this report was provided to the licensee.