306005848-10-8-2020-22-AS-RMAZ-BU7UCC-20201008152743

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005848
Report Date: 10/08/2020
Date Signed: 10/08/2020 03:28:13 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:	GOLDEN AGE SENIOR HOMES		FACILITY NUMBER:	306005848
ADMINISTRATOR:	MICO, RICO G.		FACILITY TYPE:	740
ADDRESS:	24982 WILKES PLACE		TELEPHONE:	(562) 338-4099
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY:	6	CENSUS: 6	DATE:	10/08/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Rico Mico		TIME COMPLETED:	03:00 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	Licensing Program Analyst (LPA) Ruth Martinez contacted the facility via FaceTime application, using iPhone technology, to commence a pre-licensing inspection due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the announced video call and spoke with applicant Rico Mico. An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (6) bedridden residents was submitted to CCL on 05/28/2020. Structure: The facility is a white stucco one-story house with a attached garage with 5 resident bedroom, 1 living room, 1 dining room, and a restaurant style open kitchen. The resident bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with 1 exit ways of the house with shaded seating area for residents. Signal system: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms are for 6 non-ambulatory residents. Bedrooms will accommodate 6 residents with 4 rooms being private rooms and 1 room being shared. There is 3 rooms with half a bathroom and 1 with a full bathroom. CONTINUED on LIC809-C

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020

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: GOLDEN AGE SENIOR HOMES	FACILITY NUMBER: 306005848
	VISIT DATE: 10/08/2020

NARRATIVE

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Bedrooms Staff:
No bedroom will be for live in staff.

Bathrooms:
All bathrooms have a working toilet, wash basin, walk in shower.

Linens & Hygiene Supplies:
Adequate supply of linen stored in hallways storage cabinet.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food serve for one week.

Food Service:
Adequate supply of 7-day non-perishable and 2-day perishables available.

Smoke Detectors:
Smoke detectors and carbon monoxide alert systems are hardwired, were tested and found operational.

Appliances:
Gas four-burner stove, single oven, 2 refrigerator (kitchen and garage), 1 freezer, dish washer, microwave, washer, and dryer are clean and noted to be operational.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents are stored and locked in attached garage.

Water Temperature:
Tested and recorded the water temperature measures 106 Fahrenheit degrees in all restrooms.
CONTINUED on LIC809-C

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020

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: GOLDEN AGE SENIOR HOMES	FACILITY NUMBER: 306005848
	VISIT DATE: 10/08/2020

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Medications, First-Aid Kit & Book:
Medication stored in hallway storage closet locked and inaccessible to residents. First aid kits are stored with medication.

Resident & Staff Files:
Records will be kept locked with medication storage.

Pool/Jacuzzi & Pets:
No bodies of water in facility.

Fire Extinguisher:
Mounted in wall of kitchen dated September 04, 2020.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the resident’s use, commensurate with the plan of operation.

Fire clearance:
Was approved on 09/09/2020.

Component III:
Conducted at the Pre-Licensing tele-visit, information provided about how to operate the facility within substantial compliance.

Applicant was reminded that it is required to notify LPA, within 5 business days of admitting the first resident. This notification may be done by phone, mail or fax.

All items reviewed during the tele-visit are in compliance. Facility appears to be ready for licensure. Accordingly, LPA will submit file for approval to CCL Supervisor.
Exit interview was conducted and a copy of this report was emailed to applicant and applicant agrees to submit a signed copy by email.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020

LIC809 (FAS) - (06/04)

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