306005760-6-15-2020-22-AS-MBAT-BQLVP6-20200615163612

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005760
Report Date: 06/15/2020
Date Signed: 06/15/2020 04:38:08 PM

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:	ARABELLA CARE VILLA		FACILITY NUMBER:	306005760
ADMINISTRATOR:	NORA, MARY JOYCE		FACILITY TYPE:	740
ADDRESS:	1923 WEST CHATEAU AVE		TELEPHONE:	(714) 251-4302
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	6	CENSUS: 4	DATE:	06/15/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Applicants Mary Joyce Nora and Paul Nora		TIME COMPLETED:	12:00 PM

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	At 10:00 AM, Licensing Program Analyst (LPA) Mike Barrett contacted the facility via FaceTime application, using iPhone technology, to commence a pre-licensing inspection due to COVID-19 and pre-cautionary measures. LPA identified himself and discussed the purpose of the announced video call and spoke with Applicants, Mary Joyce Nora and Paul Nora. The facility contains 4 bedrooms with 2.5 bathrooms and is a single-story building with a 2-car garage. The facility is an existing RCFE with four residents. At the time of the visit, LPA observed three (3) out of four (4) residents in the living room and one (1) in their respective bedroom. The inspection was as follows: Physical Plant: At 10:10 AM, LPA Barrett conducted the virtual inspection and toured the inside and outside of this facility with Applicants, including but not limited to the kitchen, common areas, laundry room, garage, bathrooms, bedrooms, back patio and walkways. LPA observed that the facility was clean, there were no obstructions to the interior or exterior walkways and the backyard gate, which was located on the right side of the house, was observed to be self-closing and self-latching. The kitchen was clean, and knives were stored in a locked bottom cupboard under the oven. There were smoke/carbon monoxide detectors installed throughout common areas as well as all of the bedrooms, which were centrally wired, tested and observed to be in good operation. LPA also observed another separate carbon monoxide detector in the kitchen that was tested and operational. LPA observed that there were alarms installed on all of the exit doors that were tested and observed to be functional. The fire extinguisher was located in the kitchen and was observed to be appropriately charged and mounted. Centrally Stored medications were stored in a locked cabinet that was located in living room which also contained the complete first aid kit. Cleaning supplies were stored in a locked cupboard in the laundry room above the washer and dryer. The garage was locked and inaccessible to the residents in care. Continued on page 2.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael Barrett	TELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2020

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ARABELLA CARE VILLA	FACILITY NUMBER: 306005760
	VISIT DATE: 06/15/2020

NARRATIVE

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Bedrooms:
Bedrooms were observed to have made beds, bedroom furniture, appropriate lighting and exit doors were free of obstructions.

Bathrooms:
Bathrooms were equipped with grab bars and non-skid mats in the shower stalls and the water temperatures from the faucets measured within 115 degrees F. Bathrooms were clean with all faucets and fixtures observed to be in good working order.

Supplies:
There was a sufficient supply of toilet paper and hand soap as well as a sufficient stock of linens. The facility had extra bottled water stored in the garage as well as an emergency food supply.

Food Service:
The facility met the on hand food supply requirement of 7 day perishable and 2 day non-perishable.

Records:
Residents and staff files were kept in the locked cabinet in the living room.

Administration:
LPA observed and reviewed the facility’s Emergency Disaster Plan, Resident Personal Rights and “Let-Us-No” poster posted in the facility on a central information board.

LPA conducted the Component III Orientation with the Applicants who also stated that the facility does not plan to advertise for dementia care at this time.

An exit interview was conducted with the Applicants and a copy of this report was signed by LPA, printed and sent as a PDF to the Administrator for signature and directions to scan back to LPA for facility file. An electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael Barrett	TELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2020

LIC809 (FAS) - (06/04)

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