Cromwell Haven

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Annual Inspection - Infection Control. LPA met with and explained the purpose of the visit with Administrator (AD) Percival Tobias. LPA toured the facility inside and out. Upon entry, LPA observed visitor sign in and temperature check, available masks and sanitizer. Furniture in common and dining areas are spaced to promote distancing. Facility has designated visitation areas available. LPA observed soap, paper towels and hand washing signs in bathrooms. LPA observed required food supply, paper products, available PPE and resident medications. Cleaning/disinfecting products and sharps/knives were locked. LPA reviewed resident emergency contact information. Fire and Carbon Monoxide alarms were observed in working order. LPA observed fire extinguisher which was purchased 5/2/22. AD certificate expires 10/17/23. AD has agreed to revise the symptom screening forms for residents, visitors and staff. No deficiencies were cited during this inspection. An exit interview was conducted. A copy of this report was left with Percival Tobias whose signature confirms receipt of these documents. LPA requested the following updated forms by 12/22/22: LIC 308, LIC 500, LIC 610E, LIC 9020,a copy of current Liability Coverage and revised screening forms.the state’s words, verbatim · CDSS document, Dec 15, 2022

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Katie Brown arrived at the facility to conduct the Pre-Licensing Inspection. LPA met with Ronald Sandone and Percival Tobias. LPA began the tour by entering through the front door of the home. An Emergency Evacuation Plan, Disaster Plan and required postings were observed upon entry. LPA observed Covid-19 Health Screening area including hand sanitizer and visitor sign in. Furniture in common rooms observed to be in good repair with adequate lighting throughout. Resident bedrooms have the required furnishings, lighting and bed linens including mattress covers. Smoke and Carbon Monoxide detectors present and in working order. LPA observed a supply of extra bed linens, towels, and personal hygiene/grooming products. Hot water temperature in bathrooms measured at 117 degrees F. Soap and paper towels were placed in bathrooms along with trash cans and hand washing signs posted.. Kitchen observed to have supply of dishes, cups, plates, utensils, pots and pans and cooking utensils in good repair. LPA observed a 7 day of non-perishable food. Counter tops and cabinets are clear and appropriate for food storage and preparation. Knives are kept in a locked drawer. Cleaning supplies and chemicals are stored in the locked laundry room and separate from any food items. A Washer and Dryer were observed in the laundry room with additional shelving for storage. Appliances observed to be in working order and at proper temperature. A locked storage closet for medications, First Aid Kit, Personnel and Resident files was observed and located in the hallway. First aid kit contains all required items. A fire extinguisher is present in the kitchen. Doors and passageways are unobstructed throughout the home. Outside of the facility toured. The home does not have a pool, no bodies of water or other hazards were observed. Outdoor activity space with shaded areas and seating were located on the backyard patio. LPA observed a self-releasing gate and windows have screens in good repair. Component III was conducted during pre-licensing visit with the Administrator. LPA called the designated facility phone (559) 353-2603 during the visit. The phone is set up and in working order. The applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued. An exit interview was conducted with the Administrator. A copy of this report was provided to Licensee.the state’s words, verbatim · CDSS document, Oct 19, 2021

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: INITL Capacity: 6 COMP II Participants: Percival Tobias (Board Member), Ronald J. Sandone (Administrator), and Yolanda Castigador (Secondary administrator) Interview Method: Telephone. On 9/27/2021, applicant and administrators 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 the understanding of the California Code Title 22 Regulations. 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, Sep 27, 2021