306005780-8-13-2020-22-AS-RQUZ-BSFV6N-20200813160949

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005780
Report Date: 08/13/2020
Date Signed: 08/13/2020 04:10:12 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:	CANDLEBERRY CARE		FACILITY NUMBER:	306005780
ADMINISTRATOR:	ROSARIO, ROBERTO DEL		FACILITY TYPE:	740
ADDRESS:	4216 CANDLEBERRY AVE.		TELEPHONE:	(949) 290-6006
CITY:	SEAL BEACH	STATE: CA	ZIP CODE:	90740
CAPACITY:	6	CENSUS: 0	DATE:	08/13/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Uldarico "Rico" Almiranez, Licensee and Roberto Del Rosario, Administrator		TIME COMPLETED:	03:06 PM

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Licensing Program Analyst (LPA) Rosie Quiroz conducted an announced Pre-Licensing visit with Component III Orientation via phone Face-Time virtual technology to Candleberry Care due to the Coronavirus Pandemic and precautionary measures. LPA Quiroz conducted the visit with Licensee Rico Almiranez and Administrator Roberto Del Rosario. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 03/30/2020 for a capacity of 6 Non-Ambulatory residents.

On or about 12:25pm, LPA Quiroz along with Licensee Almiranez and Administrator Del Rosario began the virtual pre-licensing inspection and observed the following:

Structure:

Facility is a one story house with 2 resident shared bedrooms, 2 private bedrooms, 2 resident bathrooms, living room, formal dining room, washer and dryer laundry area, and kitchen with dining area. The facility has a brown and beige stucco exterior with white trim. There is an attached 2 car garage. There is a front yard with minimal landscaping. The backyard has a shaded concrete area with ample outdoor furniture to accommodate residents and visitors and golf area with artificial grass on right side of backyard area. Emergency lighting and night lights were present in the facility. At 12:36pm, Fire place observed in living-room area, no fireplace screen protection observed.
Signal System:
The facility's central heating and air conditioning is controlled by a thermostat located in the living-room area. At 12:41pm, the indoor temperature was recorded to be 77 degrees Fahrenheit. Functional and Operational central heating and air conditioner.

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SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2020

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: CANDLEBERRY CARE	FACILITY NUMBER: 306005780
	VISIT DATE: 08/13/2020

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Bedrooms for Residents:
The resident bedrooms accommodate residents' furnishings such as a bed, lamp, night stand, dresser drawers and a closet. At 12:47pm, 6 of 6 resident beds were observed missing a mattress pad. Licensee Almiranez stated "Yes, we need to purchase those still."
Bathrooms:
2 of 2 bathrooms have a working toilet, wash basin, and shower/tub combination. A non-skid surface mats were present in 2 of 2 shower areas.
Linens and Hygiene Supplies:
Adequate supply of linens and hygiene supplies was present and stored in a linen closet located in a hallway outside of bathroom in hallway area above washer and dryer.
Emergency Phone Numbers, Exit Plan:
The emergency disaster plan, facility sketch and exit plan were posted in the facility towards facility entrance area. Functional and operation facility phone available in the facility.
Postings:
The Complaint poster was present and posted on a wall in an entry way of the facility. Coronavirus (COVID-19) postings were provided to the licensee but not posted throughout the facility. At 1:09pm, Administrator Del Rosario stated "We will make sure we post the COVID-19 posters."
Food Service and Menu:
There was an adequate supply of 7 day non-perishable and 2 day perishables present in the facility. The sample menu was available for review. At 1:22pm, Emergency food supplies were noted to not be available at the facility. Licensee Almiranez and Administrator Del Rosario stated "We still need to prepare with emergency bin and emergency supplies."
Smoke and Carbon Monoxide Detectors:
Smoke detector alert systems were tested and found operational. The carbon monoxide detector was tested and found to be operational.
Fire Extinguisher:
Fully charged and located in the kitchen area.
Fire Clearance:
Approved on 05/14/2020 for 6 Non-ambulatory residents.

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SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2020

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: CANDLEBERRY CARE	FACILITY NUMBER: 306005780
	VISIT DATE: 08/13/2020

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Appliances:
Electric four burner stove with overhead fan and light, single oven, refrigerator/freezer, microwave, toaster oven, and dishwasher, all are clean and noted to be operational. The washer and dryer are located in the laundry room area outside of the main hallway bathroom and noted to be in operating condition.
Toxins and Sharps:
Cleaning supplies were stored in an locked and secured cabinet located in the kitchen area. The knives and other sharp items were stored in a locked cabinet below stove in kitchen area.
Water Temperature:
Licensee measured water temperature in 2 of 2 bathrooms. The hot water temperature was recorded to be 110 degrees Fahrenheit in 2 of 2 bathrooms.
Medications, First Aid Kit & Manual:
First Aid kit with manual was available for review and stored in locked and secured cabinet in kitchen area. . The resident's medications will be stored in plastic bins that will be placed in locked and secured closet in kitchen area. At 1:47pm, No thermometers to record resident and staff body temperatures were observed in the facility. Licensee stated "We still need to purchase thermometers."
Resident and Staff Files:
Resident and staff records will be kept in a locked cabinet adjacent to the refrigerator in the kitchen area.
Reading Material, Games, Equipment, & Materials:
The facility had various materials, games, and equipment present that commensurate with their plan of operation. The following board games were observed: Scrabble, puzzles, exercising hand balls, hand weights, chess board game and yahtzee.

Component III:
At 2:19pm, LPA Quiroz conducted at the Pre-Licensing visit with Administrator Del Rosario; information provided about how to operate the facility within compliance:
The following items need to be addressed and corrected prior to licensure:

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SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2020

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: CANDLEBERRY CARE	FACILITY NUMBER: 306005780
	VISIT DATE: 08/13/2020

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A thermometer to test resident and staff body temperature
Mattress pads for 6 of 6 resident beds
Emergency preparedness supplies
Fireplace protection screen
COVID-19 posters to be displayed through out facility in pertinent areas

During the pre-licensing visit, LPA Quiroz informed Licensee Almiranez and Administrator Del Rosario that Community Care Licensing Division (CCLD) is currently working to prevent the spread of the Novel Corona Virus 2019 (COVID-19). LPA Quiroz explained to both Licensee Almiranez and Administrator Del Rosario the steps that CCLD is taking on COVID-19. LPA Quiroz also encouraged both Licensee and Administrator to visit the California Department of Public Health at https://www.cdph.ca.gov/ for more information.

Facility does not appear ready for licensure. Any items noted during today’s visit are to be corrected by August 27, 2020. LPA Quiroz will conduct a subsequent phone virtual Pre-Licensing visit to review the items listed above. An exit phone interview was conducted with Licensee Rico Almiranez and a copy of this report was signed by LPA Rosie Quiroz. This report will be sent via email to Licensee Rico Almiranez and Administrator Roberto Del Rosario who agree to sign and date the report. This report was sent via email and an electronic read receipt confirms receiving the report. Licensee Rico Almiranez agrees to send the original report by mail to the CCLD Regional Office in Orange. LPA Quiroz provided Licensee Almiranez with the Regional Office address.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2020

LIC809 (FAS) - (06/04)

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