<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004746
Report Date: 10/18/2024
Date Signed: 10/18/2024 10:55:41 AM


Document Has Been Signed on 10/18/2024 10:55 AM - 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:ALLEN'S PALM COVE RESIDENCE CAREFACILITY NUMBER:
306004746
ADMINISTRATOR:PETER NORAFACILITY TYPE:
740
ADDRESS:630 WEST STREETTELEPHONE:
(714) 310-9495
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:6CENSUS: 6DATE:
10/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Euphrosyne DimaanoTIME COMPLETED:
11:10 AM
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
This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Euphrosyne Dimaano and discussed the purpose of the inspection.
LPA reviewed Infection Control requirements. At about 8:15AM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 6-bedroom, 4-bathroom, one-story house with attached garage that is used for storage. There is a back yard with a patio cover for the residents. LPA and AD observed 3 staff and 6 residents present at the facility. Resident Bedrooms: the 6 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 114 degrees F in the common resident bathroom and 105 degrees in the two private resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen and laundry room. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are not yet due. At about 9:30AM, LPA reviewed 6 resident files and 5 staff files, interviewed 2 residents and 2 staff, and inspected medications for 6 residents. Facility does not handle resident money.
There were no deficiencies observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1