Moonraker Villa Senior Care 2

Licensing Program Analyst (LPA) Alicia Delmundo conducted an announced Component III Training via Teams Meeting with another LPA. LPA Tonica Syess-Gibson. Component III was attended by Yong Akaosugi, applicant-admininistrator. LPA Delmundo presented the training via Power Point presentation, and had a discussion with the applicant. Exit interview conducted and copy of this report provided at the conclusion of the training.

On 04/17/25 at 1:30 PM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with Administrator Yong Akaosugi and explained the purpose of the visit. LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade. The facility has a mitigation plan. Fire extinguishers were observed fully charge and tags showed serviced 08/20/2024. Water Temperature measured at 115.0 degrees At 1:52 PM LPA reviewed 4 residents records. At 2:15 PM, LPA reviewed 2 staff records and 2 of 2 were fingerprint cleared and associated to the facility. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

At 10:35 a.m. on this day, March 6, 2024, Licensing Program Analysts (LPAs) Alicia Delmundo and Tonica Syess-Gibson conducted an announced pre-licensing inspection, and met with Yong Akaosugi, applicant-administrator. License application is for six (6) total capacity, of which 2 may be non-ambulatory. Fire clearance was granted on January 16, 2024. Applicant submitted the LIC9282 Infection Control Plan and updated LIC610E Emergency Disaster Plan to Central Application Bureau (CAB) analyst. LPAs toured the facility inside out with applicant. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. Facility is a two level home on which residents will be housed on the first floor. LPAs inspected the living and family rooms, kitchen, bedrooms, bathrooms, front, side and backyard and garage. Bedrooms were observed appropriately furnished with adequate lighting and drawers. The facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed adequate for residents' use. There’s 7 days supplies of non-perishables and 2 days of perishables. Facility is equipped with refrigerator, microwave, dishwasher, washer and dryer. Storages where knives and medications will be centrally stored were observed with locks. Facility has auditory signals on all exit doors, and call buttons are readily available for residents' use. Bathrooms were observed with grab bars and non-skid mats. Fire extinguishers were observed fully charge and tags showed serviced August 2, 2023. Facility has carbon monoxide and smoke detectors that were tested, and observed operational. First aid kit inspected. Facility has flash lights for emergency lighting. Hot water temperature in the bathroom was tested and measured at 108.1 degress Fahrenheit. ....continued on 809C (page 2) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Page 2 One of the residents' rooms was observed with security window bar and with safety release device that was approved by the fire department. One of the other room has fireplace which was observed with lock. Facility has fish pond in the backyard which was observed door was secured with lock. Ombudsman and complaint posters, Right to Resident Council, Right to Family Council, Theft and Loss Program/Policy and Residents Personal Rights were observed posted in the prominent place. LPAs observed the following: -at 10:38 a.m., front door with sliding metal latch where one can put lock. -at 11:19 a.m., uneven ground/surface in the side yard. -at 11:40 a.m., cameras inside the common areas and outside the facility which have audio feature. -at 11:50 a.m., first aid kit with no tweezer and manual. -facility sketch does not indicate the dining area. -Complaint poster not of the required size. Applicant to do the following and submit proof of corrections by March 20, 2024: 1. Remove the metal latch on the front door, and submit picture. 2. Fill the uneven surface gravel and sand, and submit picture --see LIC9102 Technical Assistance 3. Remove the cameras, and submit pictures. 4. Purchase tweezer and manual, and submit proof of purchase and/or picture --see LIC9102. 5. Applicant re-arranged the furniture; however, updated sketch showing dining area to be submitted. 6. Post Complaint Poster with required size - see LIC9102. .....continued on 809C (page 3) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Page 3 LPAs reminded the applicant of the following before or upon admission of first resident: · Obtain $3M Liability Insurance coverage, and submit copy to LPA Delmundo. · Updated copy of LIC500 Personnel Report. · Updated copy of LIC308 Designation of Facility Responsibility LPA Delmundo will inform CAB analyst upon receipt of proof of corrections. Final review of application, and license to be granted by CAB analyst. Exit interview conducted, and copy of this report provided.