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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005359
Report Date: 02/15/2022
Date Signed: 02/16/2022 04:23:48 PM


Document Has Been Signed on 02/16/2022 04:23 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:CLOSE TO HOME SENIOR CARE IIIFACILITY NUMBER:
306005359
ADMINISTRATOR:PARNELL, MARICARFACILITY TYPE:
740
ADDRESS:1148 E CHESTNUT AVETELEPHONE:
(714) 872-0965
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY:6CENSUS: 4DATE:
02/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Administrator Maricar G Parnell and Ricardo EspirituTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff Ricardo and explained the reason for the visit. Staff contacted via phone call Administrator (AD) Maricar Parnell who arrived at the facility at 2:51pm. LPA observed all required postings on the wall throughout the facility. AD Maricar G Parnell has a current administrators certificate that expires on 03/28/2022. LPA was screened and temperature checked before entering the facility. LPA observed a screening log book, and temperature thermometer for screening clients and visitors. At 2:55pm LPA toured the facility with AD Maricar Parnell. There were four residents in care at the facility. All appeared to be happy and well taken care of. LPA began the tour checking client rooms and bathrooms. Client rooms have the necessary requirements, night stand, chair, lamp and dresser. All medications were locked and secure in a hallway closet. Bathrooms were operational and clean. In Bathroom #1 LPA measured the water temperature at 105.8F degrees. The facility had a two day supply of perishable food items and seven days supply of nonperishable food items. There was a first aid kit equipped with all required items. The stove was clean and all four burners were operational. Knives and hazardous chemical are locked in a cabinet above the washing machine. The facility has adequate PPE supply of gloves, N95 mask, surgical mask, and hand sanitizers. LPA observed extra linen, emergency food and water supply. LPA toured the backyard and observed both side exit gates of the house were self closing and self latching. LPA observed a shaded visitation area in the backyard equipped with tables and chairs for the residents in care. There were no bodies of water observed. Wired smoke detectors were tested and are operational. LPA observed a facility log book with up to date information regarding emergency fire drills, and facility water temperature checks. No deficiencies are being cited during todays visit. An exit interview conducted and a copy of the report was provided to the Administrator Maircar Parnell.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
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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