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Type of visit: Prelicensing

Licensing Program Analyst (LPA) Seo Jeon conducted an announced visit to conduct a Pre-licensing inspection. LPA met with Helene Moore, Applicant, for a Residential Care Facility for the Elderly (RCFE) with a capacity of five (5) residents. The facility is a four (4) bedroom with two (2) bath home with attached garage. There are three (3) resident bedrooms, one (1) staff room, kitchen/dining area, living room area, a laundry room, and a backyard. The facility does not have any known firearms or ammunition. The facility does not have swimming pool. LPA toured the interior and exterior areas of the facility. The following were inspected: All bedrooms have the required bedding and furniture, night-stands, dressers, chairs, lighting, and emergency lighting. The bathroom appliances were operating in safe and sanitary condition. The bathrooms have non-slip surfaces and grab bars. Utensils and dishware are in good repair and ready for client use. Kitchen appliances and counter-top were free of debris and in good repair. The knives and sharp objects were locked in a kitchen drawer. The water temperature was measured by LPA, the thermometer read at 108 degrees F. There are two (2) fully charged fire extinguishers in the facility. There is adequate seating in the common areas. The facility will have a storage locker that will hold resident files and staff files in garage. The facility will have medication locked in a drawer in garage.. The facility will keep the detergents and cleaning chemicals in a locked laundry room. An adequate supply of clean linens and hygienic supplies for the residents were readily available at the facility. Continued on LIC809-C..... LPA observed operating smoke detectors and carbon monoxide alarms in the facility. LPA observed required postings including the visitation policies, emergency/disaster plans, complaint procedures, and personal rights. The facility was equipped with a complete first aid kit and manual. LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPA has determined that the facility met the operational requirements for licensure. The Pre-licensing inspection is complete. The facility has satisfied all requirements in accordance with Title 22 California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to Applicant, Helene Moore.the state’s words, verbatim · CDSS document, Sep 25, 2025

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: INITIAL Capacity: 5 Census (if any clients in care): 0 COMP II Participants: Helene Moore, CEO/Administrator Interview Method: Telephone interview On September 12, 2025, 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 the 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, Sep 12, 2025