Jd Residential-Quail Hollow Villa

Type of visit: Required - 1 Year

03/27/25 10:15 AM LPAs Kayla Adkison and Rebecca Knight arrived at the facility for a required 1-year inspection. LPAs met with licensee Jeremy Potter and explained the purpose of the visit. LPAs and the licensee toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to four (4) resident rooms, common areas, three (3) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. All employees requiring background checks are cleared. Administrator certificate is current. Medications were reviewed. Medication is locked in a cabinet. The facility provides recreational activities for the residents according to their preferences and abilities. Bedding, linens, and towels for clients were observed and found to be clean and in good repair. There is an adequate supply of toiletries for the clients. The facility was observed to be at a comfortable temperature. Hot water measured between 105 – 120 degrees F. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged. Smoke detectors are all operational. No pools/bodies of water are on premises. Facility is conducting fire drills monthly and emergency evacuation drills every (3) months. In the areas toured no immediate health, safety, or personal rights violations were observed. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report was provided to licensee, Jeremy Potter,the state’s words, verbatim · CDSS document, Mar 27, 2025

Type of visit: Prelicensing

03/05/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility to conduct a Pre-Licensing inspection. LPA met with licensee Jeremy Potter, administrator Tiffany Battle, and LVN Domenique Potter and explained the purpose of the visit. Comp 3 was waived by licensee as they are currently licensed for five other facilities. The fire marshal has approved the fire safety inspection request. The facility is licensed for a total capacity of 4 ambulatory and 1 non-ambulatory clients. The inside of the facility was observed to be in good condition and repair. The facility has four (4) bedrooms, three (3) bathrooms, kitchen, dining room, living room, twwo activity areas, office, laundry closet, and patio. LPA observed a dining table with four chairs in the dining room. LPA observed couch, recliner, television and seating bench in the living room. The facility has two activity rooms, one has two easy chairs and a shelf with games and books, the second has two chairs with a small activity table and a television that will be used for karaoke. Food storage meets Title 22 regulation requirements. Plates, utensils, pots, and pans will be moved over from the previous location. Dishwasher, stove, microwave and refrigerator were all present and working. The facility has one fully charged fire extinguisher which was inspected by the fire marshal. LPA observed smoke alarms and carbon monoxide detectors fully functioning. Continued on LIC809-C The bedrooms are furnished with all required furniture and lighting. Each bedroom has ample storage. The facility has a linen closet where sheets, pillowcases ,and towels will be stored. Bathrooms were observed to be in good repair. Continued on Medications are to be stored in a locked closet. Resident and staff files will be stored in a locked office. Storage and lighting are adequate in the home. Cleaning supplies and toxins are locked up in a cabinet. Knives are locked up. Washer and dryer observed in place and ready for use. The back yard has a nice, covered patio and lawn area. LPA observed a table and chairs for residents to use. The applicants have passed the pre-licensing portion of the application process. LPA will contact the Central Application Bureau. No deficiencies according to CCR Title 22, Division 6. Exit Interview and copy of report was provided to the licensee.the state’s words, verbatim · CDSS document, Mar 5, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 4 Census (if any clients in care): 0 COMP II Participants: Potter, Jeremy - Applicant & Battle, Tiffany - Administrator Interview Method: Virtual interview (MS Teams) On 02/26/2024, 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, Feb 26, 2024