Place Like Home Assisted Living

Type of visit: Prelicensing

On 5/04/2026 at approximately 09:40 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an announced Pre-licensing visit. LPA was greeted by the Administrator, Mark Belmonte. An application was submitted to Community Care Licensing Division (CCLD) on 11/03/2025, Initial license for a Residential Care Facility for the Elderly (RCFE), 60 years old and older. The requested capacity is for five (5) non-ambulatory residents and one (1) bedridden resident. A total of six (6) capacity. The fire clearance was approved on 03/11/2026. A physical plant tour was conducted, and the following was noted: Structure: The facility is a single-story building with five (5) bedrooms and three (3) bathrooms. One (1) staff office. Entrance: There is one (1) main entrance/exit being utilized. Required postings such as: See/Say Something and Personal Rights were observed throughout the common areas. Common Areas: These include both living room and dining room. All common areas were observed to be neat, clean and organized. All common areas were properly furnished and in good repair. The facility maintains a comfortable temperature of sixty-eight (68) degrees. No firearms observed or will be maintained on the premises. A covered fireplace was observed. A working telephone was observed. Residents/staff files: Resident and staff files will be kept in locked staff office, inaccessible to residents. LIC809C-continued Kitchen: Sufficient supplies of seven (7) day nonperishable food and two (2) day perishable foods will be purchased prior to residents’ arrival. LPA observed sufficient supplies of dishes, cups and silverware readily available for the residents upon arrival. Working stove and refrigerator observed and in proper condition. The Sharps/Knives will be stored in locked kitchen drawer. The cleaning solutions/toxins were observed to be kept locked underneath the kitchen sink. Medications: The medications will be stored in a locked storage cabinet located in the kitchen. Medication storage is equipped with a lock to ensure medications will not be accessible to residents. First-aid kit observed to be equipped with but not limited to bandages, scissors, digital thermometer, tweezer and First-Aid Manuel. Emergency: The Fire extinguisher was observed to be located near the kitchen. LPA observed the fire extinguisher to be fully charged, and purchase receipt dated 01/13/2026. Bedrooms: All residents’ bedrooms were observed to be properly furnished with bed, nightstand, applicable lightening and seating. Bathroom: The bathrooms will be maintained in proper condition. Hallways: Hallway is properly lit. Extra linens/covers were observed to be stored in storage cabinets located in the hallway’s passageway. Laundry Room: The laundry room was observed to be located in the hallway’s passageway leading towards the bedrooms. LPA observed the laundry room to be kept locked. All cleaning solutions and toxins will be appropriately stored within the locked laundry room. Dryer and washer observed to be in proper condition. The Garage: The garage can be accessed from inside of the facility. The garage was observed to be located near the laundry room. LPA observed the garage to be used for storage purposes. Staff Office: The staff office will be kept locked and inaccessible to residents. Water Temperature: The water temperature will be kept within regulations of 105°F to 120°F. LIC809C-continued Smoke detectors: Dual interconnected smoke detectors and carbon monoxide observed to be working properly and were tested. Outside: The outside is clean, free of hazards, and properly furnished with sufficient seating. A shaded area for residents was observed. LPA observed a lock shed to be located in the backyard. Pool: There is no body of water located at the facility. Administration: The facility has submitted an Emergency and Disaster Plan for Residential Care Facilitates for the Elderly. The Component III Orientation for Residential Care Facility for the Elderly (RCFE) was shown/reviewed with the Administrator. Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. Exit interview conducted and copy of this report issued to the administrator.the state’s words, verbatim · CDSS document, May 4, 2026

Type of visit: Office

Facility Type: RCFE Application Type: INITIAL Capacity: 6 Census (if any clients in care): Method: Telephone call with CAB COMP II Participants: Belmonte, Mark; Veath, Mylene; Witt, Virginia On 3/25/2026, the applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Mar 25, 2026