Facility Evaluation Report

Licensing Program Analysts (LPA) Ana Soto, (LPA) Wendy Gibbs conducted an announced visit to the facility for the purpose of a Pre-Licensing evaluation. LPA's met with Ma Salvacion Medina, Licensee.

An application was submitted to Community Care Licensing Department (CCLD) on 04/25/22 for an initial license for an Residential Community Facility Elderly. They requested capacity is for (6) residents, (1) ambulatory, (4) non- ambulatory and (1) bedridden. Structure: Facility is a four (4) bedroom, two (2) full bathroom, it is a single story house with small front porch, mini ramp on the west, east, and south of the facility, covered back patio, laundry area in the 2 car attached garage. The facility is a beige stucco with half brick structure with small backyard and central air and heat. Front yard landscape is in good condition. Covered back patio has table, chairs, and storage closet. Signal System : Egress system in facility. Bedroom Residents: Bedrooms 2 & 4 will be private bedrooms and bedroom 1 & 3 will be share bedrooms. All four bedrooms are designated resident bedrooms properly equipped with regulation guidelines of one/two beds, one/two chairs, one/two night stands, one/two lamps and overhead lighting. Presently, no bedrooms are occupied. Bedroom Staff: No bedrooms will be used for awake staff. Bathrooms: 2 full bathroom are located on the west side of the facility in between bedroom #3 and bedroom #2 they have a working toilet, wash basin, and a walk-in shower with folding bench and non-skid mats. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen is stored in hallway closets. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers and menu are posted and readily available for review in the office area next to living room. Facility has not set up their land line telephone. 3 Fire extinguisher, 1- 2A10B;C mounted in living room wall, 2 - 2A10B;C mounted on the wall in the kitchen, 3 - 2A10B;C mounted on the wall of the garage, they are tagged with current annual check.