The Park at Pocket

Type of visit: Case Management - Other

On 5/30/25 at 2:30pm, Licensing Program Analyst (LPA) Kevin Gould conducted an inspection with authorized representative Toni Tin, to close the facility as the department has determined the licensee has lost control of the property as the lease of this facility was terminated March 2025. LPA has confirmed there are no resident still living at the home. Effective closure date will be 4/9/25. LPA requested a copy of the license be emailed to LPA so it can be filed with the facility closure. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, May 30, 2025

Type of visit: Prelicensing

On 10/3/24, at 1pm, Licensing Program Analyst (LPA), Arvin Villanueva conducted an announced inspection to the above facility for purpose of a pre-licensing evaluation. LPA was greeted and accompanied on inspection by facility Administrator, Exequiel Allan Fernanco (AD). The requested capacity is for 6 elderly residents. Facility is a single-story house located in a residential neighborhood. Facility has 6 single occupancy resident bedrooms and 3 full bathrooms. Upon entrance, LPA observed Complaint Poster, Personal Rights Resident Council, Ombudsman Poster and current Administrator Certificate posted on the wall of the entrance area. Going to the right is the living room and formal dining room fully furnished. Room temperature was at 74*F during this visit. Outdoor Area: Facility is across a park. Front yard was observed to be clean and free of obstructions. There is a covered patio going to the backyard. Outdoor passageways, walkways, driveways, and steps were observed to be free of obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Fence and gates were in good repair. No swimming pools/bodies of water at this time. Per AD, they will not be adding bodies of water to the property. Residents' Bedrooms: LPA observed 6 resident bedrooms. 6 of 6 resident bedrooms are fully furnished and ready for occupancy. Resident bedrooms were observed to be spacious enough to accommodate the resident's furnishings. 1 of 6 bedrooms is fire cleared for bedridden resident and is equipped with exit ramp going to the patio at the back. 1 of 6 bedroom has its own bathroom. Each bedroom is equipped with one smoke detector. Bathroom: Facility has 3 resident bathrooms. 1 of 3 bathrooms is located in one of the resident bedrooms. All bathrooms have working toilets, wash basins and full baths with showers. All bathrooms are equipped with grab bars, non-skid flooring and close-lid garbage bins. LPA observed adequate lighting in hallways leading to bathrooms. Appliances: Stove burners and oven are in good working condition. There is 1 refrigerator in the kitchen. Technical Assistance was provided to AD to obtain thermometer for the refrigerator and freezer to ensure regulatory temperature is maintained. Washer and dryer are located in the laundry room. Facility do not have a generator. Medications, First-Aid Kit: First aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and manual which are stored in a cabinet in the entrance area, available for staff use. Medications will be stored in the locked cabinet near the kitchen. Linens & Hygiene Supplies: Facility has adequate supply of linen and hygiene supplies. Emergency Phone Numbers, Exit Plan & Menu: Facility has a landline. Emergency Disaster Plan will be posted & available for review on the wall. One fully charged fire extinguisher were found in dining area. Fire extinguisher was last serviced on 10/3/24. Toxins: Toxins locked/stored under kitchen sink and in the laundry area and are inaccessible to residents. Water temperature: Hot water temperature was measured between 110*F and 111*F in 2 of 3 bathrooms. Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are in locked cabinet. Smoke Detectors and carbon monoxide: LPA observed smoke detectors in hallways, kitchen, dining area, and each of the 6 bedrooms. Carbon monoxide was observed in the hallway leading to the resident bedrooms on the right side of the facility. Smoke detector and carbon monoxide were tested and found operable during this visit. Residents & Staff Files: Applicant will not be handling cash resources of residents at this time. Activity Materials: Activity materials such as tabletop games were observed. LPA observed a TV in the living room area. There is a covered patio at the back equipped with outdoor furniture. Component III: Conducted at the Pre-Licensing visit, on 10/3/24 at The Park at Pocket, information provided about how to operate the facility within substantial compliance. Pre-Licensing is complete and this facility has no deficiencies. An exit interview was conducted with and a copy of this report was provided. Accordingly, LPA Villanueva will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant have questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.the state’s words, verbatim · CDSS document, Oct 3, 2024

Type of visit: Office

COMP II by CAB successfully completed Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 0 Method: Telephone call with CAB COMP II Participants: Exequiel Fernando, Administrator; Gloria Alejo, Owner; Shannon Betker, analyst. 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, Sep 18, 2024

Type of visit: Office

COMP II by CAB successfully completed Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 0 Method: Telephone call with CAB COMP II Participants: Antonette Tin, Administrator/Owner; Shannon Betker, analyst. 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, Jul 18, 2024