Facility Evaluation Report

Licensing Program Analyst (LPA) Karina Canela conducted an announced pre-licensing inspection on 05/12/2022.

LPA met with Applicant Charisma Mari , who will be the Administrator once the facility is approved for licensure. Additionally Liliana "Lily" Roque was present. The facility has a fire clearance approval from the Fairfield Fire Department for a total capacity of 4 Ambulatory clients (the facility does not have approval for non-ambulatory or bedridden). Facility does not have a fire clearance approval from the Fairfield Fire Department or an approved waiver from Community Care Licensing for a secured perimeter. Applicant understands they may not lock the backyard gate without prior approval. Facility will operate with 24/7 staffing (staff room available) and Licensee will ensure sufficient staffing at all times.

LPA obtained a copy of surety bond during inspection.

During today’s visit LPA observed the following items:

· COVID-19 postings and screening station; LPA was screened upon arrival.

· Lockable separate cabinets for medications, toxins/cleaners, and knives.

· All exits were unobstructed; 1 Fire Extinguisher charged and serviced 03/05/2022

· 7 smoke detectors and 1 carbon monoxide detector, which were tested and observed operational

· Complete first aid kit, night-lights leading to bathroom, and flashlight for emergency lighting

· Supply of linens, paper products, and hygiene supplies available

· Required furnishings in all 3 client bedrooms

· Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, sample food menu calendar).

· The water temperature was tested during inspection and was within regulation of 105 - 120 Degrees F

The Component III Orientation was completed; Pre-licensing is complete with no corrections needed . LPA will submit the pre-licensing application report to the Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.