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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005731
Report Date: 02/20/2025
Date Signed: 02/20/2025 03:39:52 PM

Document Has Been Signed on 02/20/2025 03:39 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:PHAMILY HOME ELDERLY CAREFACILITY NUMBER:
306005731
ADMINISTRATOR/
DIRECTOR:		PHAM, CHARLESFACILITY TYPE:
740
ADDRESS:704 E VISTA DEL PLAYA AVENUETELEPHONE:
(714) 602-6126
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Licensee Charles PhamTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On February 20, 2025, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by caregiver and granted entry after stating the purpose of the visit. Administrator (AD) Russel Cruz was present to assist with the facility inspection on today's date. Licensee/Administrator Charles Pham arrived to facility shortly after.

The facility is licensed for five (5) non-ambulatory residents, one (1) Ambulatory, one (1) bedridden with approved hospice waiver for two (2) residents. Currently, there are no (0) Hospice residents present during today’s visit.

This is a single story with a two-car detached garage home. The facility has six bedrooms and two bathrooms

LPA conducted a tour of the physical plant accompanied by Licensee/Administrator Charles Pham and Administrator Russel Cruz , and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 114.9 degrees F. A comfortable temperature of 74 degrees F. was maintained in the facility.



LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Facility has supply of emergency food and water. Facility has a fire extinguisher which was charged and mounted. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance.

CONTINUED on 809C
Lourdes MontoyaTELEPHONE: (714) 703-2870
Jenifer TirreTELEPHONE: (714) 401-6844
DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PHAMILY HOME ELDERLY CARE
FACILITY NUMBER: 306005731
VISIT DATE: 02/20/2025
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 12/2/2024. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 6/28/24 - 6/28/25. The facility is current on Community Care Licensing annual dues.

A review of four residents (R1-R4) service files and two staff (S1-S2) personnel files revealed to be complete. The facility has the current administrator's certification on file for Charles Pham - Expiration 5/19/2025

No deficiencies during this inspection visit.

An exit interview was conducted with Licensee/Administrator Charles Pham, and a copy of the report was provided.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2