306005980-9-2-2021-22-AS-RMAZ-C6GNVH-20210902104758

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005980
Report Date: 09/02/2021
Date Signed: 09/02/2021 10:48:08 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:	CARE VANNA		FACILITY NUMBER:	306005980
ADMINISTRATOR:	LESTER DEL ROSARIO		FACILITY TYPE:	740
ADDRESS:	2438 E PARKSIDE AVE		TELEPHONE:	(657) 224-9380
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY:	6	CENSUS: 4	DATE:	09/02/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lester Del Rosario		TIME COMPLETED:	11:05 AM

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 to the facility was greeted by applicant and granted entry. 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 (0) bedridden residents was submitted to CCL on 03/17/2021. Structure: The facility is a beige structure with red trim one-story house with a 2 car attached garage with 5 resident bedrooms, 1 provider room, 3 bathrooms, 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. Signal system: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms are for 6 non-ambulatory. Bedrooms will accommodate 6 residents with 5 private rooms and 1 shared bedroom accommodating two clients. Bedrooms Staff: 1 bedroom will be for live in staff. 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: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

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: CARE VANNA	FACILITY NUMBER: 306005980
	VISIT DATE: 09/02/2021

NARRATIVE

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Bathrooms:
All bathrooms have a working toilet, wash basin, bath-tub/shower. There is 1 bathroom, 1 bathroom in bedroom #1 and 1 bathroom in staff bedroom.

Linens & Hygiene Supplies:
Adequate supply of linen stored in laundry unit cabinet space.

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.

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

Appliances:
Gas four-burner stove, single oven, 1 refrigerator, 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 underneath kitchen sink, laundry unit and garage.

Water Temperature:
Tested and recorded the water temperature measures 119.7 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: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

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: CARE VANNA	FACILITY NUMBER: 306005980
	VISIT DATE: 09/02/2021

NARRATIVE

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Medications, First-Aid Kit & Book:
Medication stored in storage cabinet with lock in dining room inaccessible to residents. First aid is stored in storage unit in bedroom hallway.

Clients & Staff Files:
Records are kept locked in storage cabinet located in living room.

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

Fire Extinguisher:
Mounted in wall of the kitchen and in garage.

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

Fire clearance:
Was approved on 07/29/2021.

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: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

LIC809 (FAS) - (06/04)

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