Facility Evaluation Report

Licensing Program Analyst (LPA) Karina Canela conducted a pre-licensing inspection on 01/30/2023. LPA met with Hazel Gawat, Applicant , who will be the Administrator when the facility is approved for licensure. Applicant has approval from the Centralized Applications Bureau (CAB) for a hospice waiver to retain or accept a total of 2 residents receiving or initiating hospice services. A Dementia Care Plan of Operation has been submitted to CAB. The facility has a fire clearance approval from the City of Suisun City Fire Department for 5 non-ambulatory residents (bedrooms #1-4), 1 bedridden (bedroom #4 only) for a total capacity 6 . Facility will operate with 24 hour/ 7 days a week 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.

· 6 hardwired combination smoke and carbon monoxide detectors, plus 1 single carbon monoxide detector, 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

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

· Fire Extinguisher charged and purchased new on 01/04/2023 (receipt available for review)

· Required furnishings in all 4 resident bedrooms

· Administrator Certification; Required postings (Personal Rights, Emergency Plan/numbers, CCLD complaint poster, Rights of Family Councils, and Visitor Policy).

* Applicant to submit copy of Liability Insurance to Centralized Applications Bureau Analyst

Pre-licensing is complete and this facility has no corrections needed. The Component III Orientation was completed during today's visit. LPA will submit the pre-licensing application report to Centralized Applications Bureau (CAB) Analyst in Sacramento; CAB Analyst will notify applicant of application status.