306005359-5-20-2024-22-AS-EKIM-D5FQDQ-20240520120508

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005359
Report Date: 05/20/2024
Date Signed: 05/20/2024 12:07:06 PM

Document Has Been Signed on 05/20/2024 12:07 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	CLOSE TO HOME SENIOR CARE III		FACILITY NUMBER:	306005359
ADMINISTRATOR:	PARNELL, MARICAR		FACILITY TYPE:	740
ADDRESS:	1148 E CHESTNUT AVE		TELEPHONE:	(714) 872-0965
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY:	6	CENSUS: 4	DATE:	05/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Maricar Parnell and Greg Parnell		TIME COMPLETED:	12:20 PM

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On May 20, 2024 at 8:45am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Administrators (AD) Maricar Parnell and Gregory Parnell and explained the purpose of the visit.

The facility is licensed to operate for six (6) non-ambulatory and has a hospice waiver for four (4) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, living area, dining area, kitchen, and outside covered patio area.

LPA Kim toured inside and outside of the physical plant with AD Parnell. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each client’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. . All bedrooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, Resident Room 5 and Staff Room 1. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 112,2 degrees F. A comfortable temperature of 70 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is a two day supply of perishable and seven day supply of non-perishable food available and maintained properly. The facility has fire extinguisher that is charged, smoke detectors, and carbon monoxide were operable. A working telephone (714-660-6101) remains available. First Aid Kit contained all the necessary elements.

Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CLOSE TO HOME SENIOR CARE III	FACILITY NUMBER: 306005359
	VISIT DATE: 05/20/2024

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During the visit, LPA Kim observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and clients, and sanitizing stations. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA Kim conducted an audit of residents #1--resident #4 service files, and staff #1- staff #2 personnel files. All files were in order and complete. LPA conducted two (2) staff interviews. All residents were asleep or could not communicate for resident interviews.

Technical Violation was assessed for this visit.

An exit interview was conducted, and a copy of this report was provided to the Administrators,

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024

LIC809 (FAS) - (06/04)

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