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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005835
Report Date: 10/28/2022
Date Signed: 10/28/2022 03:57:01 PM


Document Has Been Signed on 10/28/2022 03:57 PM - It Cannot Be Edited

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 ORANGEFACILITY NUMBER:
306005835
ADMINISTRATOR:ZEHRA, SYEDFACILITY TYPE:
740
ADDRESS:1525 E TAFT AVENUETELEPHONE:
(714) 282-1409
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY:66CENSUS: 55DATE:
10/28/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:Executive Director-Sarah JohnTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to conduct a case management and health and safety check in this facility in conjunction with complaint: 22-AS-20221026170408. LPA De Perio met with Executive Director (ED) Sarah John and stated the purpose of this visit.

LPA De Perio toured the interior and exterior portions of the facility with ED John. The facility is a three level structure and is licensed for residents 60 years and over of which 66 may be non-ambulatory, 8 bedridden and a hospice waiver for 15. Currently, there are a total census of 55 residents in care of which 8 are on hospice. LPA De Perio toured both the assisted living and memory care portions of the facility. The assisted living side is made up of 23 units, and the memory care is made up of 25 units. First floor is the basement, and the second and third floor is designated for resident use.

As of 10/28/22, there are 0 COVID cases in the facility as verified. LPA De Perio observed resident bedrooms to be in good repair, and is equipped with clean linens, adequate storage space, and kept free of tripping hazards. Water temperature in restrooms were measured to be at 109.3 degrees Fahrenheit. Smoke and carbon monoxide detectors were operational and most recent fire inspection for fire alarms took place on 10/22/22 and fire sprinklers on 10/24/22, of which both inspections were passed. Auditory alarms were also tested and observed to be operational. Facility has delayed egress doors as emergency exits, of which each stairwell has an evacuation chair. Facility also has delayed egress doors in the memory care unit of which was observed to be operational. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. LPA De Perio also tested pull cords in resident bathrooms and observed to be operational.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: 10/28/2022
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Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Facility had back-up emergency food and water supply located in the basement. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged, mounted and located in multiple areas of the facility.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. LPA De Perio observed the emergency disaster and evacuation plan, which located in the ED's office.

For this visit, LPA De Perio did not observe immediate threats on the health and safety of residents in care. No citation has been issued at this time.

An exit interview was conducted with ED John and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC809 (FAS) - (06/04)
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