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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005723
Report Date: 12/03/2020
Date Signed: 12/04/2020 10:41:50 AM

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:INFINITE LOVE RESIDENCE 1FACILITY NUMBER:
306005723
ADMINISTRATOR:ADOLFO, GIANNINA MARIEFACILITY TYPE:
740
ADDRESS:4451 SOUTHERN POINTE LANETELEPHONE:
(714) 485-2459
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 4DATE:
12/03/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gianna Adolfo and Jed AdolfoTIME COMPLETED:
10:20 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
Licensing Program Analyst, Kathrina Chin contacted the facility via telephone and Facetime App for a pre-licensing evaluation due to COVID-19 and for pre-cautionary measures. LPA Chin identified herself and spoke to Giannina Adolfo and Jed Adolfo, Administrators ad discussed the purpose of the vitual visit. The facility has five bedrooms and four bathrooms and is a single story with a three car garage. This pre-licensing inspection is due to a change of ownership and the facility has four residents in care at this time. The inspection is as follows:

A fire clearance was granted on October 30, 2020 for 6 non-ambulatory residents of which 1 may be bedridden. This facility has submitted a hospice waiver request for 3 residents.

LPA toured the facility, interior and exterior, including all resident bedrooms. Hot water were tested in three bathrooms and observed to be between 105-108 degrees Fahrenheit. Fire extinguishers were mounted and charged. Smoke detectors were centrally wired throughout and have been checked by the fire department. Carbon monoxide detectors are operational. There is a sufficient supply of linens. Bedrooms are appropriately furnished. There is sufficient lighting. There are non-skid mats in the showers.

There was one locked medication cabinet which stores two first aid kits. There were several locked closets for storage of toxins and cleaning equipment. All exit has auditory devices. There are four residents bedrooms and one bedroom for the care staff. The kitchen area was checked and there is a sufficient supply of food items. There were emergency food supplies and water. LPA observed activity calendars, theft and loss policy, residents rights, admission agreement, resident rights and emergency plans were posted including the Ombudsman and Let Us Know posters. LPA reviewed the outdoor area and observed a lattice patio with outdoor furniture.

(Continued on LIC 809C)
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2020
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: INFINITE LOVE RESIDENCE 1
FACILITY NUMBER: 306005723
VISIT DATE: 12/03/2020
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
26
27
28
29
30
31
32
(Continued)

A Component III was completed during visit with Giannina Adolfo, Administrator. LPA reviewed Personnel Policies, Prohibited Health Conditions, Fingerprinting, Abuse Reporting Procedures, In-Service Training and Medication Procedures.

It appears that this facility meets the requirements for licensure. Both the license and the hospice waiver will be granted upon final review and approval from the Central Applications Bureau.
.

A telephonic exit interview was conducted with Administrator, Giannina Adolfo and a hard copy of this report was provided via email for signature.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2020
LIC809 (FAS) - (06/04)
Page: 2 of 2