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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005899
Report Date: 11/19/2020
Date Signed: 11/19/2020 04:21:05 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:IN R GREAT HANDS - MONTEVIDEOFACILITY NUMBER:
306005899
ADMINISTRATOR:IN, RIZAFACILITY TYPE:
740
ADDRESS:1261 MONTEVIDEO AVENUETELEPHONE:
(714) 646-9648
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 0DATE:
11/19/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Applicant Riza InTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Michelle Reed contacted the facility via telephone to commence an announced Prelicensing visit due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call with Riza In and Denise Molde. Mrs. In will be the designated Administrator for the facility.
An initial application to operate an Residential Care Facility for the Elderly was submitted to the Central Applications Unit (CAU) on 9/23/20 for a capacity of 6 residents of which 4 will be non-ambulatory. The Orange County Fire Department conducted a Fire Safety Inspection on 10/20/20 and granted a fire clearance. A tour of the physical plant was conducted inside and out at approximately 11:30 am. with Mrs In. Facetime was used for the inspection and the following was observed:
Structure:
Facility is a one story house with 5 bedrooms and 3 bathrooms. Bedroom #1 through #5 are designated as resident rooms and are authorized for nonambulatory resident use. There is also a living room, dining area and kitchen. There is no staff room at this time.
Signal System:
Central air/heating system installed with a central panel to control entire house.
Bedrooms Residents:
The resident bedrooms( #1-#5) accommodate residents' furnishings and meet Title 22 regulation at this time.
Bathrooms:
Two bathrooms have a working toilet, wash basin, and shower. The 3rd bathroom is a Toilet and wash basin only. Grab bars and non-slip mats were present.
Linens and Hygiene Supplies:
Adequate supply of linens was observed
Ombudsman Poster, Personal Rights and See Something Say Something Poster
Awaiting Ombudsman poster and others will be posted at time of licensure. Board for posting was present
Food Service:
Adequate supply of 7-day non-perishable and 2 day perishables are stored in the kitchen and pantry and will include fruits and vegetables.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020
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: IN R GREAT HANDS - MONTEVIDEO
FACILITY NUMBER: 306005899
VISIT DATE: 11/19/2020
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Smoke and Carbon Monoxide Detectors:
Smoke detectors and carbon monoxide systems were observed working at the time of this visit
Fire Extinguishers:
The fire extinguishers were mounted and fully charged at the time of this visit
Fire Clearance:
Approved on 10/20/20
Appliances:
Refrigerator/freezer and microwave which were clean and noted to be operational. Washer and dryer were clean and noted to be operational.
Toxins:
Will be locked and inaccessible to residents
Water Temperature:
Tested and recorded at degrees F.
Medications, First Aid Kit & Manual:
First Aid kit with guide will be stored with resident medications. Medication will be stored and locked in the facility living area.
Resident and Staff Files:
Records will be kept locked for privacy
Component III
Component III was conducted

The Prelicensing is complete and this facility has no deficiencies.

The Licensee will be granted upon a final review by the Central Applications Bureau and approval by management.

An exit interview was conducted with Riza In and a copy of this report was emailed for signature.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020
LIC809 (FAS) - (06/04)
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