Facility Evaluation Report

Licensing Program Analyst(LPA) arrived to conduct a Pre-Licensing Inspection, on 6/20/24 at approximately 9:15am, and was greeted by Xiaohong Wang-Administrator. LPA also met with Xiangzhong Fan, Administrator back-up, who arrived a short time later. This prelicensing is being conducted for a change of ownership application. The facility is currently licensed as "Caremax, INC- Pomo Home #496801809.

Component III orientation was completed today, 6/20/24, with both Administrators, Xiaohong Wang and Xiangzhong Fan.

Facility has received a fire clearance approval from the local fire department- effective 1/30/24 for five (5) ambulatory clients. Fire extinguishers, two were observed to be in the green zone area, meaning both were appropriately pressurized as required. Facility has smoke alarms and a carbon monoxide detector as required. Facility has a required infection control plan. Facility has required emergency disaster plan. LPA conducted a walk through of the home that will serve four clients once licensed. LPA observed the following: Facility has a sufficient supply of food. Facility had all medications locked up and inaccessible to clients in care. All cleaners and disinfectants were locked up and inaccessible to clients in care. There was an emergency food supply, including water in case of a disaster and/or facility emergency. Facility had a first aid kit, including the first aid guide book. Hot water temperature was checked at 109.4 degrees Fahrenheit. Facility has a large backyard deck off the living room slider door; Off the deck is a ramp that leads to the fire exit gate of the backyard.

The following needs to be corrected: Walls need to be cleaned and painted where needed. Facility will clean both bathrooms showers/tubs, sinks, and floors as needed. Curtains hanging in a resident room need to be cleaned. Floors in resident rooms need to be cleaned. Cleaning of the backyard, sweeping off the deck from debris, and clear all spider webs. Administrator to organize and ensure there are sufficient supplies of all linens, including sheets, pillow cases, blankets, and towels for all clients use.

Administrator (s) will enure the above items are completed in a timely manner, and notify the LPA of all corrections being done; Submit to the LPA how the items were corrected, and submit pictures and receipts as proof of correction. Once the LPA obtains documentation, they will be reviewed, and the LPA will contact the applicant/Administrators. The LPA will notify the application analyst when all items have been corrected.