306005939-8-18-2021-22-AS-RMAZ-C5ZQPR-20210818122109

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005939
Report Date: 08/18/2021
Date Signed: 08/18/2021 12:26:21 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:	ADULT CARE OC I		FACILITY NUMBER:	306005939
ADMINISTRATOR:	SCHOTT, BRIAN		FACILITY TYPE:	740
ADDRESS:	25032 WOOLWICH ST		TELEPHONE:	(626) 864-9955
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY:	6	CENSUS: 6	DATE:	08/18/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Brian Schott		TIME COMPLETED:	12:35 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 made an announced visit to the facility for the purpose of a pre-licensing evaluation. LPA arrived at facility was greeted at the door by caregiver and granted entry. Upon entry LPA was check in per COVID guidelines, check in station observed at front door. LPA met with Brian Schott, applicant and explained the process of the evaluation. An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (6) capacity, (1) ambulatory, (5) non-ambulatory, and (0) bedridden residents was submitted to CCL on 12/10/2020. Structure: The facility is a two-story house with an attached garage with 6 bedrooms, 1 caregiver room, 5 resident bedrooms, 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 2 exit ways on each side of the house with shaded seating area for residents. Second Floor: No residents residing in second floor of house. Signal system: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms are for 1 ambulatory and 5 non-ambulatory residents. Bedrooms will accommodate 6 residents with 4 bedrooms being private and 1 being shared with 2 bedrooms having half a bathroom in each. CONTINUED on LIC809-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

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: ADULT CARE OC I	FACILITY NUMBER: 306005939
	VISIT DATE: 08/18/2021

NARRATIVE

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Bedrooms Staff:
1 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 storage cabinet in hallway.

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 are to be stored in the kitchen. Extra refrigerator in garage for surplus of food.

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

Appliances:
Gas five-burner stove, single oven, 2 refrigerators (kitchen and garage), dish washer, microwave, toaster oven, 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 110.1 Fahrenheit degrees in all restrooms.
CONTINUED on LIC809-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

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: ADULT CARE OC I	FACILITY NUMBER: 306005939
	VISIT DATE: 08/18/2021

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

Resident & Staff Files:
Records kept locked and stored with medication storage closet.

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

Fire Extinguisher:
Mounted in wall in kitchen.

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 06/24/2021.

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

All items reviewed during the 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 left with the applicant.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

LIC809 (FAS) - (06/04)

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