Facility Evaluation Report

Licensing Program Analyst (LPA) Karina Canela conducted a pre-licensing inspection on 11/28/2022. LPA met with Applicants Selene Cruz -Astroga and Romar Raquino who will be the Administrator when the facility is approved for licensure. The facility has a fire clearance approval from the Fairfield Fire Department for 1 non-ambulatory (bedroom #1) and 3 ambulatory residents (bedrooms #2-4) for a total capacity 4. Facility will operate with 24/7 staff and Licensee will ensure sufficient staffing at all times.

During today’s visit LPA observed the following items:

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

· 6 hardwired combination smoke and carbon monoxide detectors, which were tested and observed to be operational

· First Aid kit, night-lights in hallways leading to bathrooms, and flashlights for emergency lighting

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

· Grab bars and non-slip shower flooring in 2 of 2 bathrooms.

· Required furnishings in all 4 resident bedrooms

· A shed in the backyard used for storage

· Administrator Certifications; Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, Client personal rights and visitor policy).

Pre-licensing is complete and this facility has no deficiencies .

The Component III Orientation was completed during today's visit. LPA will submit the pre-licensing application report to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.