306005810-6-8-2020-22-AS-JAUT-BQDT86-20200608142950

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005810
Report Date: 06/08/2020
Date Signed: 06/08/2020 02:30:18 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:	DEVOTED FAMILY CARE HOME		FACILITY NUMBER:	306005810
ADMINISTRATOR:	PICENO, CASSANDRA		FACILITY TYPE:	740
ADDRESS:	12041 GILBERT ST		TELEPHONE:	(949) 381-9225
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY:	6	CENSUS: 0	DATE:	06/08/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:28 PM
MET WITH:	Cassandra Piceno		TIME COMPLETED:	02:29 PM

NARRATIVE

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Licensing Program Analyst (LPA) James August conducted an announced Pre-Licensing visit with Component III Orientation via a virtual video telephone call to Devoted Family Care Home due to COVID-19 and precautionary measures LPA August conducted the visit with Administrator Cassandra Piceno. Administrator Piceno has administrator certificate expiring on 3/19/2022. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 03/01/2020 for a capacity of 4 non-ambulatory residents and 2 ambulatory residents.

Facility is a one story house with 4 resident bedrooms, 1 staff bedroom, 2 resident bathrooms, 1 staff bathroom, living room, dining area, kitchen and office. There is an attached 2 car garage. The backyard has a shaded concrete area with seating for residents as well as a large grassy area. There was no debris on the side walkways or backyard. There is a self latching exit gate on the side walkway.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Bathrooms had one locked cabinet for any toxins. Water temperature measured 116.0 degrees in resident bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Auditory alarms tested operational. Kitchen was inspected and appliances are in working order. Sharps, medications and toxins are kept in locked kitchen cabinets.

Smoke detectors and carbon monoxide detectors are hardwired and tested operational during today's visit. Fire extinguishers were fully charged. The facility has 2 brand new first aid kits. There are no security bars or weapons on the premises. Component III conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

CONTINUED ON LIC 809C DATED 06/08/2020...

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: James August	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2020

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: DEVOTED FAMILY CARE HOME	FACILITY NUMBER: 306005810
	VISIT DATE: 06/08/2020

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The items reviewed during today’s visit are in compliance. Facility appears ready for licensure. The license will be granted upon completion of a final review and approval from the Central Applications Bureau.

An exit phone interview was conducted with Administrator Piceno and a copy of this report was signed by LPA James August. This report will be sent via email to Administrator Piceno who agrees to sign the report and return same via email within 24 hours.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: James August	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2020

LIC809 (FAS) - (06/04)

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