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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005835
Report Date: 08/17/2022
Date Signed: 08/22/2022 10:29:19 AM


Document Has Been Signed on 08/22/2022 10:29 AM - 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: 54DATE:
08/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:ED Sarah JohnTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for the purpose of conducting a Required 1 Year inspection. LPA was greeted and granted entry by Executive Director Sarah John and reason for visit was explained.

Upon entry LPA was screened per COVID guidelines. LPA tour the facility with Executive Director Sarah John. The facility currently has 54 residents in care, of which 11 are receiving Hospice services. LPA observed residents watching TV in family room. Facility appears clean and sanitary. All resident's rooms had the required elements as well as restrooms stocked with soap/sanitizer. LPA observed the screening/sanitizing station in the entrance of the facility. Visitors sign in and are screened for temperature. Facility takes resident temperatures daily and documents. Facility has COVID precaution postings as well as all required department postings. Facility has completed the Mitigation Plan and is approved. LPA observed adequate emergency food and water supply as well as the First Aid kit which contained all required items. Facility has all required items of PPE on site. LPA toured the outside grounds and observed ample shaded outside visitation area. LPA observed the medication locked in medication cart. Facility has a plan for COVID testing residents and staff as needed as well as a plan for isolation. Staff and most residents are vaccinated for COVID-19.LPA Frank tested the hot water temperature, which measured 113.1 degrees F in resident bathroom. Resident areas were noted to be a comfortable temperature. Smoke detectors and carbon monoxide detector were tested and are operational. Fire extinguishers were fully charged. Fire drill was conducted 8/02/22.
LPA Frank reviewed Emergency Disaster Plan (LIC610E); LIC 9020A Client Roster; LIC 808) Mitigation Plan and Current Liability Insurance; Designation of Administrative Responsibility (LIC308) and Personnel Report (LIC500).
Based on the observations made during today’s visit, no deficiencies are being cited in area inspected.
This report was discussed with the facility representative and a copy was provided.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Shobhana FrankTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
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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