Facility Evaluation Report

Licensing Program Analyst (LPA) Mariana Agban conducted a Pre-Licensing Inspection with Administrator Angela Apoyan. A Change in Ownership (CHOW) Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on May 15, 2023. A fire clearance was approved on October 31,2023 for two (2) ambulatory residents, three (3) non ambulatory residents and one (1)bedridden resident, for a total capacity of six. The bedridden fire clearance is for room #4. A dementia plan of operation has been submitted. Hospice waiver has been requested for three (3) residents which is pending approval of Manager. The garage is to be used as a garage only.

The smoke alarms and carbon monoxide detector are battery operated and functional . The facility has one fire extinguisher that was purchased on July 11, 2023. The fire extinguisher is located in dining room area.

A tour of the physical plant was initiated at approximately 10:20 am and the following was observed:

The facility is a two-story building. The facility sketch that was submitted to CCL was just for the first floor. From the first floor, there is a stairwell that leads to the 2nd floor. The stairwell has a door that is being kept locked. On the 2nd floor, there are two bedrooms each has a private bathroom. The 2nd floor is furnished. Administrator stated that the 2nd floor is being used by the landlord. The landlord lives out of the country and once or twice a year comes back to the country. Administrator mentioned that currently future staff live in one of the rooms on the 2nd floor.

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives were observed locked in a kitchen drawer. BEDROOMS: There are four (4) bedrooms designated for residents use. Bedroom #1 and #2 are private rooms for ambulatory residents. Bedrooms #3 and #4 are shared rooms with bedroom #4 having a bedridden fire clearance (per STD 850). The applicant furnished the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space. (Continue on 809C)