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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003406
Report Date: 07/22/2021
Date Signed: 07/23/2021 02:43:02 PM

Document Has Been Signed on 07/23/2021 02:43 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:ORANGE MANOR, THEFACILITY NUMBER:
306003406
ADMINISTRATOR:AIDA MARTIRESFACILITY TYPE:
740
ADDRESS:1824 NORTH SHAFFER ST.TELEPHONE:
(714) 283-2474
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY: 6CENSUS: 4DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Aida MartiresTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced visit for the purpose of conducting a Required 1 Year inspection. LPA was greeted and granted entry by Caregivers Ofelia Santos and David Tagalicud. LPA advised Caregivers the reason for the visit. Administrator Aida Marites arrived shortly after and reason for visit was shared.

Upon entry LPA was screen per COVID guidelines. LPA began the tour of the facility. The facility currently has 4 residents in care. LPA observed 2 residents in the living room relaxing, and 2 residents asleep in their bedroom, All residents appeared happy and well taken care of. Facility appears clean and sanitary. Facility staff screens all visitors to the facility and LPA observed the screening station in the entrance of the facility. Facility keeps documentation in regard to COVID for all the visitors, staff, and resident. LPA observed hand washing guidelines posted in all bathrooms of facility. LPA observed facility has COVID precautionary posting throughout the facility as well as all required Department postings. Facility has an active COVID-19 prevention plan in place for the safety of residents in care. LPA observed ample of emergency food and water as well as First Aid kit in the facility. Facility has an ample supply of PPE, incontinence, and cleaning supplies. Facility has sanitation precaution in place. LPA observed caregivers cleaning and sanitizing facility. LPA toured the outside and observed 2 shaded outside space for resident, area can be used for outdoor visitation as well. Facility has a plan for COVID testing residents and staff as needed as well as a plan for isolation as needed. Facility has 4 private bedrooms, 2 shared bedrooms, and 1 staff bedroom. During the walk through, LPA observed the Sunroom is being converted into a kitchen. LPA obtained a copy of Mitigation Plan.

Based on the observations made during today’s visit, no deficiencies were noted per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Administrator and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2021
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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