306005836-4-1-2021-22-AS-SHAD-BZNNTQ-20210401104507

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005836
Report Date: 04/01/2021
Date Signed: 04/01/2021 10:45:24 AM

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:	CASA DOLCE HOME		FACILITY NUMBER:	306005836
ADMINISTRATOR:	EMIGH, JEANINE		FACILITY TYPE:	740
ADDRESS:	1601 SKYLINE DRIVE		TELEPHONE:	(707) 580-5609
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92831
CAPACITY:	6	CENSUS: 0	DATE:	04/01/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Administrator Jeanine Emigh		TIME COMPLETED:	10:35 AM

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	Licensing Program Analyst (LPA) Sean Haddad conducted this announced inspection for the purpose of conducting a Pre-licensing inspection via tele-visit due to COVID-19 and for precautionary measures. LPA met with Administrator (AD) Jeanine Emigh, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to CCL on 05/03/2020. At 9:10 AM, LPA and AD observed the following: Structure. This is a one-story home. Facility is a 4-bedroom, 3-bathroom, 1 story house with detached garage that is being used for storage and kept locked. There is a back yard with a patio cover for the clients. Facility telephone number is (714) 213-8423 and mobile number is (707) 580-5609. Facility email address is JEANINE@CASADOLCEHOME.COM. Bedrooms Residents. The 4 client bedrooms are spacious and will easily accommodate the client's furnishings. Lamps, chairs, linens, and storage for each client bedroom inspected. Bedrooms staff. This facility has no staff bedrooms. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 114 to 120 F degrees. During the inspection, AD adjusted the water heater temperature to ensure water temperature does not rise past 120 F degrees. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. 7 days nonperishable food supply reviewed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detector/carbon monoxide detector. Appliances. New Stove burners, microwave, washer, and dryer inspected. Knives: observed locked/stored in the kitchen cabinet. Toxins: observed in the locked laundry room. Medication cabinet is locked. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files. This is an initial inspection, LPA reviewed resident and staff storage area. Fire clearance was approved by Fullerton Fire Department Inspector Peggy Castaneda on 03/12/2021. Backyard. Backyard exit gate is operational and unlocked. Backyard has shaded area for outdoor activities and sufficient seating for residents. (Continued)

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021

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: CASA DOLCE HOME	FACILITY NUMBER: 306005836
	VISIT DATE: 04/01/2021

NARRATIVE

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During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AD was informed today that the facility is ready for licensure and final approval will be processed by the CAU supervisor in Sacramento. Component III was completed with AD during today’s inspection. An exit interview was conducted with AD via tele-visit. This report will be emailed and an electronic email read receipt confirms receipt of the report. AD agrees to send a signed copy by email.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021

LIC809 (FAS) - (06/04)

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