Facility Evaluation Report

Licensing Program Analyst (LPA) Kelly Dulek conducted an announced Pre-Licensing inspection at the facility today and met with Licensee Representative/Applicant Ivy Sudjati. Entrance interview conducted.

The facility obtained a fire clearance on 11/03/2023 for 6 (six) bedridden, with a total capacity of 6 (six) residents. The Licensee Representative submitted a hospice waiver request and was approved for 6 (six) hospice residents. Component II was completed on 04/16/2024. During today's visit, LPA completed Component III with the Applicant Representative.

The facility is a single-story home in the Oxnard area, which consists of 5 (five) bedrooms and 4 (four) bathrooms. There is no staff room and Applicant stated that staff will remain awake at night. Beginning at 09:58AM, the LPA, along with Applicant Representative, conducted a physical plant tour to ensure there are no health and safety hazards and the facility is in compliance with regulation. The following was observed:

KITCHEN/FOOD SERVICE AREA: The facility has a sufficient supply of non-perishable foods, emergency food and water. Knives and sharp items will be stored in a locked box. Cleaning supplies and disinfectants will be stored underneath the locked kitchen sink and in the locked garage. The facility has a sufficient supply of plates, cups and utensils.

RESIDENT BEDROOMS/BATHROOMS: The resident bedrooms were observed. 2 (two) bedrooms are fully furnished for resident use. 1 (one) additional bedroom is currently furnished for staff use, but the Applicant indicated once licensed, this room will be utilized for residents only. The resident bathrooms were observed to be clean and sanitary with grab bars and non-skid mats. Hot water was measured in a common resident restroom and measured within the required range. The facility has a sufficient supply of linens and towels.