Facility Evaluation Report

Licensing Program Analyst (LPA), Tiffany Holmes conducted an announced Pre-Licensing visit to observe the facility's compliance with Title 22, Division 6 regulations and the California health and code. LPA met with Administrator, Sally Saif, Administrator. Facility is applying to serve six (6) clients 18-59 years of age. (4) rooms at the facility and (3) bathrooms.

During today's visit LPA, accompanied by Sally Saif, Administrator conducted a facility tour. LPA observed resident rooms and found them to have proper furnishings, and adequate linens. Sinks accessible to residents had running water. Facility temperature read at 72 degrees Fahrenheit. Facility had a working fire extinguisher. Smoke and carbon monoxide alarms were observed and operational. The Fire Department granted clearance on 04/26/2022. Administrator stated that there will be no weapons or ammunition kept on the facility property. Staff and resident records will be stored in a locked cabinet downstairs. There is a shaded outdoor space and appropriate resident activities. All cleaning supplies or potentially hazardous materials were locked. Facility has a locked area for resident medications and first aid kits. Administrator Certificate expires on 05/19/2023. Component III was reviewed with the Administrator. The application will be sent to the Centralized Application Bureau for final review and approval.

An exit interview was conducted with Sally Saif, Administrator. A copy of this report and Licensee Appeal Rights (LIC 9058 01/16) was provided.