306005775-12-1-2020-22-AS-SFRK-BVW3BS-20201201170651

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005775
Report Date: 11/23/2020
Date Signed: 12/01/2020 05:07:27 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:	BABB STREET MANOR		FACILITY NUMBER:	306005775
ADMINISTRATOR:	MCKEEVER, SEAN		FACILITY TYPE:	740
ADDRESS:	2959 BABB ST		TELEPHONE:	(562) 207-7216
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 0	DATE:	11/23/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	12:57 PM
MET WITH:	Sean McKeever		TIME COMPLETED:	03:45 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 Analyst (LPA) Shobhana Frank made a FaceTime application call to the facility, using iPhone technology, to commence a pre-licensing inspection due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the announced video call and spoke with Administrator Sean MCKEEVER. An initial application to operate a Residential Care for Elderly ages (60) and above Facility application, for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden residents was submitted to CCL on 11/03/2020. Structure: The facility is a one story house with an attached garage with 5 bedrooms, living room, 5 bathrooms, 2 bathrooms are attached to bedroom 1 and bed room #3, 2 full bathrooms for the residents and one half bathroom for the facility staff 1 dining room, and a kitchen. The resident bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with 2 exit ways on each side of the house with shaded seating area for residents. Signal system: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms are for 6 non-ambulatory resident. Bedrooms will accommodate 6 residents with one bedroom rooms being shared and four bedrooms being private. Bedroom #1 and # are equipped with a full bathroom. CONTINUED on LIC809-C

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020

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: BABB STREET MANOR	FACILITY NUMBER: 306005775
	VISIT DATE: 11/23/2020

NARRATIVE

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Bathrooms:
All bathrooms have a working toilet, wash basin, walk in shower.

Linens & Hygiene Supplies:
Adequate supply of linen stored in laundry unit.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food serve for one week.

Food Service:
Adequate supply of 7-day non-perishable and 2-day perishables are to be stored in the kitchen.

Smoke Detectors:
Smoke detectors and carbon monoxide alert systems are hardwired, were tested and found operational.

Appliances:
Gas five burner stove, single oven, 1 refrigerator, dish washer, microwave, washer, and dryer are clean and noted to be operational.

Toxins:
All and any toxic chemicals, cleaning solutions, and disinfectants are inaccessible to residents are stored and locked in attached garage and laundry toxins stored in laundry unit.

Water Temperature:
Tested and recorded the water temperature measures 112.6 Fahrenheit degrees in all restrooms.
CONTINUED on LIC809-C

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020

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: BABB STREET MANOR	FACILITY NUMBER: 306005775
	VISIT DATE: 11/23/2020

NARRATIVE

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Medications, First-Aid Kit & Book:
Medication stored in storage cabinet locked in office inaccessible to residents. First aid kit is mounted in the wall of the kitchen.

Resident & Staff Files:
Records will be kept locked in storage cabinet located in office.

Pool/Jacuzzi & Pets:
No bodies of water in facility.

Fire Extinguisher:
Mounted in wall in kitchen and bedroom hallway.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the resident’s use, commensurate with the plan of operation.

Fire clearance:
Was approved on 10/26/2020.

Component III:
Conducted at the Pre-Licensing tele-visit, information provided about how to operate the facility within substantial compliance.

Applicant was reminded that it is required to notify LPA, within 5 business days of admitting the first resident. This notification may be done by phone, email, mail or fax.

All items reviewed during the tele-visit are in compliance. Facility appears to be ready for licensure. Accordingly, LPA will submit file for approval to CCL Supervisor.
Exit interview was conducted and a copy of this report was emailed to applicant and applicant agrees to submit a signed copy by email.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020

LIC809 (FAS) - (06/04)

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