Dolores Homecare II

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to the facility to conduct a case management visit on the health, safety, and welfare of residents in care. LPA met with the Administrator, ANALISA CAYABYAB. LPA was informed that six (6) residents currently reside at this facility, with a capacity of six (6). There were two (2) staff on duty during the time of the visit. LPA toured the facility and observed all facility utilities to be on and operating without issues. Food supply is sufficient. There is no immediate concern for residents in care. No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted with Administrator, ANALISA CAYABYAB and a copy of this report is left with the her, as evidence by her signature.the state’s words, verbatim · CDSS document, Oct 10, 2023

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to the facility to conduct a case management visit on the health, safety, and welfare of residents in care. LPA met with the Licensee, Analisa Cayabyab. LPA was informed that five (5) residents currently reside at this facility, with a capacity of six (6). There were two (2) staff on duty during the time of the visit. LPA toured the facility and observed all facility utilities to be on and operating without issues. Food supply is sufficient. There is no immediate concern for residents in care. No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted with Licensee, Analisa Cayabyab and a copy of this report is left with the her as evidence by her signature.the state’s words, verbatim · CDSS document, Aug 30, 2023

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Kathleen Banrasavong conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At 11:20 AM, LPA met with Administrator, Anson Cayabyab. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 01/03/2023 for a total capacity of six (6) residents. Fire clearance was granted on 03/10/2023. LPA Kathleen Banrasavong observed the following: Structure: Facility is a one-story house with four (4) resident bedrooms, three (3) resident bathrooms, living room, dining area and kitchen. There was an attached two car garage in the front of the house. There is a pool with a 5 foot secured, locked gate. There is one (1) secured fireplace. Heating/Cooling System: Central heating and air conditioning system are installed and operable. Temperature was set at 74 degrees. Bedrooms: Each resident bedroom #1, #2, #3, #4 was in good repair. Four (4) resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm and carbon monoxide alarms. Bathrooms: Three (3) resident’s bathrooms have a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and hand soap dispensers. At 12:20 PM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 108 degrees Fahrenheit. (CONTINUED ON LIC 809-C) (CONTINUATION FROM LIC809C) Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp drawer will be secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition. Pantry had sufficient storage for non-perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the house. Laundry detergents and cleaning supplies were observed in a closet away from residents. Living/Family room: There was a living room with furniture for all clients. Linens and Hygiene Supplies: An adequate supply of linens and hygiene supplies was stored in a cabinet in the hallway of the residence. Yards/Outside: Patio table and chairs were observed in the backyard. There was a gate on the northwest side and a self-latching lock. All outdoor pathways were free of obstructions. Emergency Phone Numbers, and Exit Plan: Facility sketch were observed posted at the exits in the house. Ombudsman poster, Let-Us-No poster, Rights of Resident Council, Theft & Loss, Personal rights, Non-discrimination observed. General items: One (1) fire extinguisher was charged and located in the closet with signage; fire extinguisher was charged 03/13/2023. Six (6) smoke alarms and two (2) carbon monoxide detectors were tested and were observed to be in working order. Client records will be stored in a locked cabinet in the kitchen dining room area. Two (2) First Aid kits with required components were observed. There was a locked area for medication storage. Emergency food and water supply was observed. Pre-Licensing is complete, and this facility has no deficiencies. An exit interview was conducted, and a copy of this report was given Administrator, Anson Cayabyab.the state’s words, verbatim · CDSS document, Aug 22, 2023

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to the facility to conduct a case management visit on the health, safety, and welfare of residents in care. LPA met with the Administrator, Anson Cayabyab. LPA was informed that seven (7) residents currently reside at this facility, with a capacity of six (6). There were nine (9) staff on duty during the time of the visit. LPA toured the facility and observed all facility utilities to be on and operating without issues. Food supply is sufficient. There is no immediate concern for residents in care. Due to the state of emergency of having to relocate all residents from Affinity Senior II, LPA observed seven (7) residents at the facility. The capacity is six (6), the Administrator stated that he will be moving R1 to Affinity Senior Living by August 23, 2023. The Administrator states that they have sufficient PPE, first aid requirements, gloves. No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted with Administrator, Anson Cayabyab and a copy of this report is left with him as evidence by his signature.the state’s words, verbatim · CDSS document, Aug 22, 2023

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): 6 COMP II Participants: Anson Cayabyab (applicant, licensee, Administrator), Analisa Cayabyan (applicant, licensee) Interview Method: microsoft teams On 7/6/23, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. 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, Jul 6, 2023