306005835-8-5-2020-22-AS-SFRK-BS7VBD-20200805161721

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005835
Report Date: 08/05/2020
Date Signed: 08/05/2020 04:18:19 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:	KIRKWOOD ORANGE		FACILITY NUMBER:	306005835
ADMINISTRATOR:	WALKER, ALETA		FACILITY TYPE:	740
ADDRESS:	1525 E. TAFT AVENUE		TELEPHONE:	(714) 282-1409
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY:	66	CENSUS: 43	DATE:	08/05/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:37 AM
MET WITH:	Virtual tele vist Executive Director Aleta Walker		TIME COMPLETED:	01:10 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	LPA Shobhana Frank contacted Executive Director Aleta Walker and identified herself and discussed the purpose of the call with Executive Director Aleta Walker. This is a pre-existing facility and this visit was conducted due to a change of Ownership. Change of Ownership application was submitted to CCL on 5/4/2020 for a capacity of 68 Resident. Fire clearance was granted on 6/3/20. LPA along with Executive Director Aleta Walker virtual toured the entire community, interior and exterior, including a sampling of resident apartments. Following was observed: The main structure is a two story residential building with a basement. This building includes 48 resident units in total. The entire community was designed to accommodate 66 non-ambulatory residents. The secured Memory Care area is on the 1st floor with delayed egress and has a capacity of 65 with 16 residents at Assisted Living and 28 residents at Memory Care total 43 resident currently occupied. This facility submitted a hospice waiver request for 15 residents. All residents will furnish their own homes, provide their own linens, etc. Hot water was tested in 6 resident apartments between 110.8 – 112.2 degrees F. Fire extinguishers were mounted and charged. Smoke detectors with sprinkler systems were centrally wired throughout the facility and have been checked by the fire department. There were additional linens available in Memory Care. There was a locked medication room on the 2nd floor residents who need medication management. There were several locked janitorial closets for storage of toxins and cleaning equipment. An emergency call system was in place in each apartment. The facility has a pendant system along with roam alert for residents who need them. .First aid kits were observed in the medication room and kitchen. Facility has a variety of food available for residents. Nonperishable and perishable food is sufficient stocked with food to meet the regulatory amounts. LPA observed posted activity calendars, menus and available activities. LPA observed required posted LET-US-NO, Resident's Rights, and Ombudsman posters. An activity room, outdoor patios, library and beauty salon were available for resident use.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2020

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: KIRKWOOD ORANGE	FACILITY NUMBER: 306005835
	VISIT DATE: 08/05/2020

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Component III was completed during the visit. LPA observed Personnel Policies, Abuse Reporting Procedures, In-Service Training and Medication Procedures.

During the virtual tour LPA observed COVID -19 Signs were posted throughout the facility to promote handwashing, cough/sneeze etiquette, and social distancing.
• Staff members are screened, and temperatures taken once a shift. The PCC and recommended that screening and temperatures be taken twice a shift.
• Residents are screened, and temperatures taken twice a day.
• The facility has at least 60 days’ worth of PPEs, hand sanitizers, disinfectants, cleaning supplies, and food supplies.
• All Three meals, snacks and hydration are currently delivered to resident’s rooms. As per PIN 20-23 in one week, the facility will initiate staggered dining with a maximum of 6 residents per meals. Residents will still have meals delivered to their rooms per request.

The items reviewed during today’s visit are in compliance. Facility appears to be 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 ED Aleta Walker, this report LIC 809 and LIC 809C was signed by LPA Shobhana Frank. A copy of this report will be sent via email to ED 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: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2020

LIC809 (FAS) - (06/04)

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