306005987-3-29-2023-22-AS-RMAZ-CQDPQ6-20230329113038

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005987
Report Date: 03/29/2023
Date Signed: 03/29/2023 11:30:55 AM

Document Has Been Signed on 03/29/2023 11:30 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ATLANTA HOUSE		FACILITY NUMBER:	306005987
ADMINISTRATOR:	LOPEZ, ANICIA		FACILITY TYPE:	735
ADDRESS:	2204 S ATLANTA ST		TELEPHONE:	(714) 539-0696
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92802
CAPACITY: 6		CENSUS: 4	DATE:	03/29/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Martin Lopez		TIME COMPLETED:	12:00 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 conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at facility was greeted at the door by staff and granted entry. An initial application to operate an Adult Residential Facility (ARF) Age range 19 through 59, for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden clients was submitted to CCL on 03/23/2021. Structure: The facility is a one story house with an attached garage with three resident bedrooms, one staff bedroom, three full bathrooms, one dining room, one living room, a kitchen, and an office space. The client’s bedrooms are spacious and will easily accommodate the client’s furnishings. There is a large backyard with an exit way on each side of the house. There is covered seating for the clients in the backyard. Air/Heating: Central air/heating system installed with a central panel to control entire house. Bedrooms Clients: Bedrooms will accommodate six clients with three shared bedrooms accommodating two clients per. Bedrooms Staff: There is a bedrooms designated for live in staff with a full bathroom. Continued on LIC809-C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ATLANTA HOUSE	FACILITY NUMBER: 306005987
	VISIT DATE: 03/29/2023

NARRATIVE

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Bathrooms:
All bathrooms have a working toilet, wash basin, walk in shower.

Linens & Hygiene Supplies:
Adequate supply of linen stored in hallway storage 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 seven-day non-perishable and two-day perishables are stored in the kitchen. Pantry is located in storage room.

Smoke Detectors:
Smoke detectors and carbon monoxide alert systems are hardwired, were tested and found operational. Fire extinguishers charge and mounted in kitchen dated 03/21/23.

Appliances:
Gas four-burner stove, single oven, two refrigerators (one is located in garage), one freezer (located in garage), microwave, dishwasher, dryer, and washer are clean and noted to be operational.

Toxins:
All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to clients are stored and locked in storage cabinet.

Continued on LIC809-C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ATLANTA HOUSE	FACILITY NUMBER: 306005987
	VISIT DATE: 03/29/2023

NARRATIVE

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Water Temperature:
Tested and recorded maintained at a comfortable temperature and the water temperature measures 105.1 Fahrenheit degrees in client’s bathroom.

Medications, First-Aid Kit & Book:
Medication and First Aid kit stored in locked storage cabinet located in dining room.

Resident & Staff Files:
Records will be kept in locked cabinet located next to medication cabinet.

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 08/05/21.

Component III:
Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities.

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.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

LIC809 (FAS) - (06/04)

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