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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005974
Report Date: 05/13/2021
Date Signed: 05/13/2021 02:29:02 PM

Document Has Been Signed on 05/13/2021 02:29 PM - It Cannot Be Edited

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:LA HABRA PLAZAFACILITY NUMBER:
306005974
ADMINISTRATOR:DIA, GERALDFACILITY TYPE:
740
ADDRESS:2630 RAINIER WAYTELEPHONE:
(310) 989-8633
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY: 6CENSUS: 3DATE:
05/13/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator (AD) Gerald DiaTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Sean Haddad conducted this announced inspection for the purpose of conducting a Pre-licensing inspection via pre-scheduled and pre-planned tele-visit, with future inspections to be conducted on site. LPA met with Administrator (AD) Gerald Dia, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 02/26/2021. This is a change of ownership.

At 9:00 AM, LPA and AD observed the following. LPA stopped the inspection at 11:50 AM and resumed at 1:00 PM. Structure. This is a one-story home. Facility is a 5-bedroom, 2-bathroom, 1 story house with detached garage that is being used for storage and kept locked. There is a back yard with a patio cover for the clients. Facility telephone number is (562) 905-0034. Facility email address is lahabraplazaguesthomes@gmail.com. Bedrooms Residents. The 4 client bedrooms are spacious and will easily accommodate the client's furnishings. Lamps, chairs, linens, and storage for each client bedroom inspected. Bedrooms staff. The 1 staff bedroom is spacious and will easily accommodate the staff’s furnishings. Lamps, chairs, linens, and storage for each staff bedroom inspected. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 114 to 115 F degrees. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. 2 days perishable and 7 days nonperishable food supply observed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detector/carbon monoxide detector. Appliances. New Stove burners, microwave, washer, and dryer inspected. Knives: observed locked/stored in the kitchen cabinet. Toxins: observed in the locked laundry room cabinet. Medication cabinet is locked. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files. LPA reviewed resident and staff files. Fire clearance was approved by Los Angeles County Fire Department Inspector R. Smith on 04/28/2021. Backyard. Backyard exit gate is operational and unlocked.
(Page 1)
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2021
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: LA HABRA PLAZA
FACILITY NUMBER: 306005974
VISIT DATE: 05/13/2021
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 Backyard has shaded area for outdoor activities and sufficient seating for residents. Component III was completed with AD during today’s inspection. Facility is currently operating under the liability insurance of current facility FAMILY HOME CARE (306003795). AD will switch liability insurance to new facility once the application is approved.

During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AD was informed today that the facility is ready for licensure and final approval will be processed by the CAU supervisor in Sacramento. An exit interview was conducted with AD via tele-visit. This report will be emailed and an electronic email read receipt confirms receipt of the report. AD agrees to send a signed copy by email.

(Page 2)
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
LIC809 (FAS) - (06/04)
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