Facility Evaluation Report

Licensing Program Analyst (LPA) A. Canela conducted a pre-licensing inspection and met with Applicant/Administrator Mark Jayson Sy. Fire clearance was approved by the Vallejo Fire Department on 8/9/2021 for a total of 6 residents, of which 3 are Non-ambulatory and 3 are Ambulatory. LPA successfully conducted a component III orientation with Mark Jayson Sy.

LPA toured facility and observed: Facility is a one story home, in good repair and at a comfortable temperature. Hot water temperature checked between 107 and 108 degrees F in 2 out of 2 resident's faucets as required by Title 22 Regulations. The facility has a phone line designated for residents' use. Personnel and residents' records are stored at a locked kitchen cabinet.

The home includes kitchen, dining area, 4 bedrooms, 2 bathrooms, living room, provider room/office and garage. Required posting for facility were observed, along with several Covid guidance posters. The facility has a table in front area by door with sign in sheet, hand sanitizer, thermometer and small garbage can.

During today’s visit LPA observed the following items:

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

· 7 hardwired smoke detectors, 2 carbon monoxide detectors 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

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

· Required furnishings in resident bedrooms

· Fire Extinguisher charged and serviced 5/13/2021

· Administrator Certification for Mark Jayson Sy #6042012740 exp. 9/19/22

Mitigation Plan was received on 9/10/2021 and approved

Pre-licensing is complete, no corrections needed and can proceed with licensure. Application Unit Analyst will notify applicant of application status.