306000629-8-1-2022-22-AS-ETAA-CGVREN-20220801125748

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306000629
Report Date: 08/01/2022
Date Signed: 08/01/2022 12:58:28 PM

Document Has Been Signed on 08/01/2022 12:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	CUDDLE CARE HOME		FACILITY NUMBER:	306000629
ADMINISTRATOR:	NELLIE MAE CAUDLE		FACILITY TYPE:	740
ADDRESS:	416 E. CHESTNUT AVE.		TELEPHONE:	(714) 282-8951
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY:	5	CENSUS: 2	DATE:	08/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Nellie Mae Caudle		TIME COMPLETED:	01:10 PM

NARRATIVE
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	Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection in this facility. LPA met with Administrator Nellie Mae Caudle and stated the purpose of this visit. The facility is a single level structure and licensed for five non-ambulatory with a hospice waiver for three. This facility is a Residential Care Facility for the Elderly/Hospice. At about 11:30 AM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 2 residents in care and Administrator on duty. LPA toured the interior and exterior portions of the facility. There were 2 resident rooms and 2 staff rooms. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors and carbon monoxide alarms were tested to be operational. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 105.9 degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to residents in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed mounted. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. LPA did notice gardening tools to be out but were inaccessible to residents in care. The exterior portion of the facility also contained a swimming pool with a gate surrounding the pool and a locked latched door. Garage is kept locked and used for storage and equipped with an operational washer and dryer. Kitchen was in good repair with medications and sharp items kept locked. LPA Tapia reviewed the COVID 19 mitigation plan of the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CUDDLE CARE HOME	FACILITY NUMBER: 306000629
	VISIT DATE: 08/01/2022

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LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. No citation was issued. No advisory was issued today.

LPA Tapia conducted an exit interview with Administrator Nellie Mae Caudle and copy of this report was explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

LIC809 (FAS) - (06/04)

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