Facility Evaluation Report

Licensing Program Analyst (LPA) Karina Canela conducted a pre-licensing inspection on 12/20/2021. LPA met with Applicant Julie Martuscello who will be the Administrator when the facility is approved for licensure. The facility does not have any pending waiver requests. The facility has a fire clearance approval from the Fairfield Fire Department of 4 non-ambulatory for a total capacity of 4. Facility will operate with a live-in staff and Licensee will ensure sufficient staffing at all times.

During today’s visit LPA observed the following items:

· COVID-19 postings and screening station at entrance

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

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

· First Aid kit, night-lights, and flashlights for emergency lighting

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

· Fire Extinguisher charged and serviced 03/17/2021

· Required furnishings in all 4 resident bedrooms

· Administrator Certification (EXP: 07/23/2023)

· Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, and visitor policy).

LPA requested the following updated documents:

- Facility sketch (LIC999) to reflect live-in staff bedroom

- Emergency Disaster Plan (LIC 610D) section 1 - Assignments During an Emergency

- Facility Mitigation Plan (LIC808) pages 8 and 14

Pre-licensing is incomplete with corrections needed

The Component III Orientation was completed during today's visit.

Once corrections are received from applicant, LPA will submit the pre-licensing application report to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.