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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005914
Report Date: 05/20/2021
Date Signed: 05/20/2021 10:24:07 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:SENIOR'S RETREAT, INC.FACILITY NUMBER:
306005914
ADMINISTRATOR:SMITH, LORNAFACILITY TYPE:
740
ADDRESS:312 GUAVA PLACETELEPHONE:
(714) 332-0685
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:6CENSUS: 0DATE:
05/20/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Lorna Smith, AdministratorTIME COMPLETED:
10:43 AM
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Licensing Program Analyst (LPA) Jim August conducted an announced visit to the facility for purpose of a pre-licensing evaluation and Component III. LPA August was greeted and granted entry by Administrator Lorna Smith. Administrator Smith has an administrator certificate which expires on June 30, 2021. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on October 15, 2020 for a capacity of 6 non-ambulatory residents.

LPA August along with Administrator Smith toured the facility. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of 5 resident bedrooms, 2 resident bathrooms, living room, dining room, family room and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 118.0 and 118.4 degrees in resident bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps in a locked chest under the kitchen burners. LPA toured the locked garage and observed additional food, water and emergency supplies. Smoke detectors and carbon monoxide detectors are hardwired and tested operational during today's visit. Fire extinguishers were fully charged. Outside grounds were toured and no bodies of water were observed. LPA noted the outdoor walkways had chairs and household items that were planned to be discarded soon. There are no security bars or weapons on the premises. Exit gate is unlocked and will require a self latching mechanism be added.

LPA observed the first aid kit contained all required items including tweezers, thermometer, and scissors. LPA confirmed the facility has an active certificate of insurance for liability. Continued on LIC809C...

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James AugustTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
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: SENIOR'S RETREAT, INC.
FACILITY NUMBER: 306005914
VISIT DATE: 05/20/2021
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Medications are stored in a locked cabinet. The facility will offer several activities such as special occasion/holiday activities, games, bingo, enjoy outdoor time, music therapy, church services, gardening and exercises.

The facility is ready to be licensed. As noted above, a Component III was conducted during this visit as well.

An exit interview was conducted and a copy of this report was provided to applicant.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James AugustTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
LIC809 (FAS) - (06/04)
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