306005840-8-18-2020-22-AS-MRED-BSLTM9-20200818145043

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005840
Report Date: 08/18/2020
Date Signed: 08/18/2020 02:51:56 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:	NOTHING HILLS GUEST HOME LLC		FACILITY NUMBER:	306005840
ADMINISTRATOR:	MIRABUENO, MARIA		FACILITY TYPE:	740
ADDRESS:	13901 HEWES AVENUE		TELEPHONE:	(213) 446-1695
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92705
CAPACITY:	6	CENSUS: 5	DATE:	08/18/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Licensee Jasmin Avila		TIME COMPLETED:	10:45 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) Michelle Reed conducted an announced Pre-Licensing visit via FaceTime due to the Coronavirus Pandemic and precautionary measures. LPA Reed conducted the visit with Licensee Jasmin Avila. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 5/28/20 for a capacity of 6 non-ambulatory residents. This is a change of ownership. The facility was previously licensed as Foothill Assisted Living. LPA Reed conducted a virtual tour of the facility at approximately 9:15 am with Ms. Avila and the following was observed: Structure: Facility is a one story house with 4 resident bedrooms, 3 bathrooms, 1 staff bedroom, living room area, dining area, and kitchen. There is an attached 2 car garage. The backyard is large and has patio seating for residents. The exit gates on the exterior of the home have self-closing and self-latching mechanisms. Signal System: The facility's central heating and air conditioning is controlled by a thermostat located in a hallway. All interior exit doors were equipped with an auditory alarm and were noted to be in operating condition. The facility has a call button system for some of the residents. Bedrooms Residents: All bedrooms accommodate non-ambulatory residents. At this time there is no fire clearance for bedridden residents. Bedroom #5 is designated for staff. Emergency lighting was present throughout the facility. Resident bedrooms accommodate residents' furnishings. Bathrooms: There are 3 bathrooms in the facility. One bathroom had a toilet and sink and shower. The other bathrooms have a toilet, wash basin, and walk-in shower. Grab bars were present as well as a non-skid mats. Linens and Hygiene Supplies: Adequate supply of bed linens, towels and hygiene supplies were present.Emergency Phone Numbers, Exit Plan: Readily available for review with a facility sketch and exit plan posted

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2020

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: NOTHING HILLS GUEST HOME LLC	FACILITY NUMBER: 306005840
	VISIT DATE: 08/18/2020

NARRATIVE

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Postings:
The Ombudsman and Complaint posters are present in the facility and posted in common areas
Food Service and Menu:
There was an adequate supply of 7 day non-perishable and 2 day perishables present in the facility. There is an additional refrigerator located in the garage.
Smoke and Carbon Monoxide Detectors:
Smoke alert systems are hardwired were tested and found operational. The carbon monoxide detector was tested and found operational.
Fire Extinguisher:
Fully charged and mounted on a wall in the kitchen with two others present if needed.
Fire Clearance:
Approved on 7/9/2020.
Appliances:
Gas four burner stove with an exhaust system with a light, single oven, refrigerator/freezer, microwave, and dishwasher. The washer and dryer are located in the laundry room leading to the garage and were noted to be in operating condition.
Toxins and Sharps:
Locked and stored in the garage. The knives and other sharp items are stored in a locked kitchen drawer.
Water Temperature:
The water temperature tested at 114 degrees F which meets regulation guidelines.
Medications, First Aid Kit & Manual:
First Aid kit and manual present in the facility. Medication was stored in a separate locked closet.
Resident and Staff Files:
Resident and staff records are kept in a locked cupboard
Reading Material, Games, Equipment, & Materials:
The facility did have sufficient reading materials and games
Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2020

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: NOTHING HILLS GUEST HOME LLC	FACILITY NUMBER: 306005840
	VISIT DATE: 08/18/2020

NARRATIVE

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The Prelicensing is complete and the facility has no deficiencies.

The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau.

An exit interview was conducted with Licensee Jasmin Avila and a copy of this report was provided via email. An electronic email read receipt, confirms receiving these documents. Ms. Avila agreed to receive the copies of the report and to return a signed copy.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2020

LIC809 (FAS) - (06/04)

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