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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005760
Report Date: 06/10/2024
Date Signed: 06/10/2024 04:43:21 PM


Document Has Been Signed on 06/10/2024 04:43 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:ARABELLA CARE VILLAFACILITY NUMBER:
306005760
ADMINISTRATOR:NORA, MARY JOYCEFACILITY TYPE:
740
ADDRESS:1923 WEST CHATEAU AVETELEPHONE:
(714) 251-4302
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 4DATE:
06/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Mary Joyce NoraTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by Administrator (AD) Mary Joyce Nora.

The facility is a one-story home with five resident bedrooms, one resident bathroom, kitchen, dining room, living room, common area, staff room, staff bedroom, laundry area, backyard and attached 2-car garage. Facility appears clean, safe and sanitary. LPA noted residents were lounging in the common area, resting in their rooms or walking outside with staff.

All resident rooms had required elements, including bed, chair, closet space and ample lighting. Facility has extra linens and hygiene supplies for residents in the hallway closet. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured between 105 and 120 degrees F. LPA observed facility has emergency food and water supply. LPA observed the fire extinguisher was last serviced in September of 2023. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in the kitchen and the laundry area. Knives are locked up separate from toxic chemicals. Medication for each resident is kept locked in a cabinet in the common area. The backyard has a shaded sitting/lounging area. Exit gate is unlocked and self latching. LPA observed exit gate to be unobstructed. LPA reviewed two resident files and two staff files. LPA also reviewed medication for two residents. LPA interviewed one staff and one resident. Facility has musical instruments, electronics and plenty of space for resident activities.

No deficiencies noted during today's inspection. An exit interview was conducted and a copy of this report and was provided to the facility

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024
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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