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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006021
Report Date: 08/06/2021
Date Signed: 08/06/2021 11:22:57 AM

Document Has Been Signed on 08/06/2021 11:22 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SIANI ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
306006021
ADMINISTRATOR:ESPANA, SHARONDAFACILITY TYPE:
735
ADDRESS:4591 LARKSPUR CIRCLETELEPHONE:
(909) 767-7030
CITY:ANAHEIMSTATE: CAZIP CODE:
92807
CAPACITY: 4CENSUS: 0DATE:
08/06/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Sharonda EspanaTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Michelle Reed conducted an announced visit to the facility to commence a Prelicensing visit. Upon arrival, LPA met with Applicant Sharonda Espana. A Change of Ownership application(Individual to Corporation) to operate an Adult Residential Facility was submitted to the Central Applications Unit (CAU) on 5/19/21 for a capacity of 4 residents of which 4 will be ambulatory. The Anaheim Fire Department conducted a Fire Safety Inspection on 4/14/21 and granted a fire clearance. There are currently no residents present. Ms. Espana is awaiting to be approved by the OC Regional Center for clients. A tour of the physical plant was conducted inside and out at approximately 10:45am with Ms. Espana and the following was observed:
Structure:
Facility is a one story house with 6 rooms and 3 bathrooms. Bedroom #1 through #4 are designated as resident rooms. Room #5 will be the activity room and Room #6 the staff room. There is also a living room, dining area and kitchen. Patio chairs and an umbrella was provided in the patio area. Gates were self latching and walkways were free allowing for safe exiting.
Signal System:
Central air/heating system installed with a central panel to control entire house.
Bedrooms Residents:
The resident bedrooms( #1-#4) accommodate residents' furnishings and meet Title 22 regulation at this time.
Bathrooms:
Two bathrooms have a working toilet, wash basin, and shower. The 3rd bathroom is a Toilet and wash basin only. Grab bars and non-slip mats were present.
Linens and Hygiene Supplies:
Adequate supply of linens was observed
Ombudsman Poster, Personal Rights and See Something Say Something Poster
Ombudsman poster, resident rights and See Something Say Something poster were posted at the time of visit.
Food Service:
Applicant stated that an adequate supply of non-perishable and perishables foods will be stored in the kitchen and pantry once residents are present. Food will include fruits and vegetables.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2021
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: SIANI ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 306006021
VISIT DATE: 08/06/2021
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Food Service:
Applicant stated that an adequate supply of non-perishable and perishables foods will be stored in the kitchen and pantry once residents are present. Food will include fruits and vegetables.
Smoke and Carbon Monoxide Detectors:
Smoke detectors and carbon monoxide systems were present and observed working at the time of this visit
Fire Extinguishers:
The fire extinguisher was mounted and fully charged at the time of visit
Fire Clearance:
Approved on 4/14/21
Appliances:
Refrigerator/freezer and microwave which were clean and noted to be operational. Washer and dryer were clean and noted to be operational.
Toxins:
Will be locked and inaccessible to residents
Water Temperature:
Tested and recorded at 116 degrees F.
Medications, First Aid Kit & Manual:
First Aid kit with guide will be stored with resident medications. Medication will be stored and locked.
Resident and Staff Files:
Records will be kept locked for privacy
Component III
Component III was conducted

Emergency food and water will also be obtained
Infection Control procedures and PPE were also in place.

The Prelicensing is complete and this facility has no deficiencies.

The License will be granted upon a final review by the Central Applications Bureau and approval by management.

An exit interview was conducted with Sharonda Espana and a copy of this report was given.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
LIC809 (FAS) - (06/04)
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