306005773-8-4-2020-22-AS-CTRD-BS6RTE-20200804131815

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005773
Report Date: 08/04/2020
Date Signed: 08/04/2020 01:18:41 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:	FAMILY CHOICE SENIOR LIVING		FACILITY NUMBER:	306005773
ADMINISTRATOR:	CSUKARDI, ANITA		FACILITY TYPE:	740
ADDRESS:	3105 W. ORANGE STREET		TELEPHONE:	(714) 229-0069
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	30	CENSUS: 15	DATE:	08/04/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Shazad Khan - Administrator		TIME COMPLETED:	01:20 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	Licensing Program Analysts (LPA's) Criss Trinidad and Patricia Velazquez conducted an announced Pre-Licensing visit with Component III Orientation via phone FaceTime virtual technology to Family Choice Senior Living due to the Coronavirus Pandemic and precautionary measures. LPAs Trinidad and Velazquez conducted the visit with Administrator Shazad Khan and Anita Csukardi. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 01/07/2020 for a capacity of 30 non-ambulatory residents. LPAs Trinidad and Velazquez along with administrator Khan and Csukardi observed the following: Structure: Facility is a one story house with 15 resident bedrooms, 8 bathrooms, 1 administrator office, living room area, 2 dining areas, and kitchen. The facility has white stucco exterior with brown trim. There is a front yard with grass and then a concrete patio. There is two table with seating for residents. The backyard has concrete a table and seating for residents. The exit gates on the exterior of the home have self-closing and self-latching mechanisms but are not in operating condition. Signal System: The facility's central heating and air conditioning is controlled by multiple NEST thermostats throughout the facility. The main exit doors were equipped with an auditory alarm and were noted to be in operating condition. The facility has a call bracelet system for all residents. which were tested and found operational. The facility had a video camera present in resident bedrooms, common areas and kitchen . Bedrooms Residents: All bedrooms accommodate non-ambulatory residents. Emergency lighting was present throughout the facility but there were no night lights present in the bedrooms or bathrooms. The resident bedrooms accommodate residents' furnishings.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Criss Trinidad	TELEPHONE: (714) 321-8277
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2020

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: FAMILY CHOICE SENIOR LIVING	FACILITY NUMBER: 306005773
	VISIT DATE: 08/04/2020

NARRATIVE

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Bathrooms:
There were 8 bathrooms in the facility. The bathrooms have a toilet, wash basin, and walk-in shower. Grab bars were present as a well as a non-skid mat.
Linens and Hygiene Supplies:
Adequate supply of bed linens are stored in a linen closet located in a hallway. The hygiene supplies were stored in the bathrooms. There was adequate supply of towels present in the facility.
Emergency Phone Numbers, Exit Plan:
Readily available for review in the entry hallway with a facility sketch and exit plan.
Postings:
The Ombudsman and Complaint posters are present in the facility. Complaint poster was not in the correct size.
Food Service and Menu:
There was an adequate supply of 7 day non-perishable and 2 day perishables present in the facility. There is 1 additional refrigerator/freezers located in the storage area. There was a sample menu available for review. There were no additional emergency food supplies present in the facility.
Smoke and Carbon Monoxide Detectors:
Smoke alert systems are hardwired were tested and found operational. The carbon monoxide detector was tested and found operational.
Fire Extinguisher:
5 Fully charged and mounted fire extinguishers were available and serviced on 2/2/22.
Fire Clearance:
Approved on 03/17/2020 for 30 non-ambulatory residents.
Appliances:
Gas 8 burner stove with an exhaust system, dual oven, refrigerator/freezer, microwave, and 2 dishwashers. There were 2 washers and dryers are located in the laundry room and were noted to be in operating condition.
Toxins and Sharps:
Locked and stored in a locked cabinet in the staff bathroom. The knives and other sharp items are stored in a locked kitchen drawer.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Criss Trinidad	TELEPHONE: (714) 321-8277
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2020

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: FAMILY CHOICE SENIOR LIVING	FACILITY NUMBER: 306005773
	VISIT DATE: 08/04/2020

NARRATIVE

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Water Temperature:
The water temperature for al bathrooms were in the range of 105.8-114.4 degrees.
Medications, First Aid Kit & Manual:
There was a First Aid kit and manual present in the facility. Medication was stored in a locked fridge and a locked cart in the dining area.
Resident and Staff Files:
Resident and staff records are kept with the medications in a locked administrator office.
Reading Material, Games, Equipment, & Materials:
The facility had sufficient materials, games, and equipment present.
Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance.

The following items need to be addressed and corrected prior to lincesure.

Insufficient seating in dining areas
Inoperable auditory alarms on exit doors
Insufficient seating in outdoor patios
Insufficient seating in living room
Ensure exit gate is self closing and self latching
Complaint poster in correct size 20x26
Emergency food supplies
Repair and replace inoperable stove top burners
Remove excessive black stains surrounding burners
Remove executive black grease stains on oven, door and rack
Replace or clean stain in toilet of bathroom 1
All renovations to be completed
Remove cameras from resident bedrooms

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Criss Trinidad	TELEPHONE: (714) 321-8277
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2020

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: FAMILY CHOICE SENIOR LIVING	FACILITY NUMBER: 306005773
	VISIT DATE: 08/04/2020

NARRATIVE

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Facility does not appear ready for licensor. Any items noted during today's visit are to be corrected by September 4, 2020. LPAs Trinidad and Velazquez will conduct a subsequent FaceTime Pre-Licensing visit to review the item listed above. An exit phone interview was conducted with Administrator Khan and Csukardi and a copy of this report was signed by LPA Trinidad. This report will be sent via email to Administrator Khan who agrees to sign and date the report. This report was sent via email and an electronic read receipt confirms receiving the report. Mr. Khan agrees to send the original report by mail to the CCLD Regional Office (RO) in Orange.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Criss Trinidad	TELEPHONE: (714) 321-8277
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2020

LIC809 (FAS) - (06/04)

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