306005382-2-28-2024-22-AS-ARJR-D2VW33-20240228155514

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005382
Report Date: 02/28/2024
Date Signed: 02/28/2024 03:58:56 PM

Document Has Been Signed on 02/28/2024 03:58 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ORANGE HILLS CARE HOME		FACILITY NUMBER:	306005382
ADMINISTRATOR:	MAY WALLACE		FACILITY TYPE:	740
ADDRESS:	130 NORTH ROTH LANE		TELEPHONE:	(714) 771-7753
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	6	CENSUS: 5	DATE:	02/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:07 PM
MET WITH:	Ricardo Alberto-Caregiver, Emerlene Zarate-Administrator		TIME COMPLETED:	04:11 PM

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Caregiver Ricardo Alberto. Administrator (AD) Emerlene Zarate arrived shortly after.

For today’s visit, LPA observed a total of 5 residents in care and 2 staff members on duty.

LPA observed the Administrator's Certificate for facility AD Emerlene Zarate which expires on 09/03/2024.

LPA Ramirez toured the interior and exterior portions of the facility with AD Zarate. The facility is a single level structure and is licensed for 6 non-ambulatory residents, of which 4 may be on hospice and 0 bedridden. For this visit, there are a total of 5 residents in care. There are a total of 5 bedrooms, of which 4 are private resident rooms, and 1 private bedroom for staff. LPA Ramirez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 2 restrooms of which 1 is a private restroom. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 109.0-110.8 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged, and located in the hallway.

CONTINUED ON LIC809-C...

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

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: ORANGE HILLS CARE HOME	FACILITY NUMBER: 306005382
	VISIT DATE: 02/28/2024

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LPA Ramirez observed the emergency disaster and evacuation plan, which is posted by the kitchen. Facility had back-up emergency food and water supply, located in the garage. LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPA Ramirez observed a shaded patio area with furniture, and the grounds were free of any hazards. There is 1 gate in the backyard, which is self-closing and self-latching. No bodies of water were observed.

LPA reviewed five resident files and three staff files. LPA interviewed residents and staff present.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with AD Zarate.

A copy of this report was provided at the time of exit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

LIC809 (FAS) - (06/04)

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