306006022-8-30-2021-22-AS-RMAZ-C6DPQC-20210830113055

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006022
Report Date: 08/30/2021
Date Signed: 08/30/2021 11:31:11 AM

Document Has Been Signed on 08/30/2021 11:31 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:	CALIFORNIA HOME CARE		FACILITY NUMBER:	306006022
ADMINISTRATOR:	MALLARI, ANNA		FACILITY TYPE:	735
ADDRESS:	15672 CALIFORNIA STREET		TELEPHONE:	(657) 600-8434
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY: 4		CENSUS: 0	DATE:	08/30/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Anna Mallari		TIME COMPLETED:	11:40 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 conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA was greeted by and granted entry by Anna Mallari. An initial application to operate an Adult Residential Facility (ARF) was submitted to CCL on 06/02/21 for a capacity of four non-ambulatory clients. LPA observed the following: Structure: Facility is a one story house with 4 client bedrooms, 1 staff bedroom, 2 bathrooms, and a 2 car attached garage. The facility is a beige stucco exterior with white trim. There is a large, covered patio area in the rear with seating for the clients. The client bedrooms will accommodate resident’s furnishings. There is a back yard with an exit on each side. Signal system: Central air/heating system installed with a central panel to control entire house. Bedrooms Client: Four bedrooms will accommodate non-ambulatory residents with each room accommodating one client. Bathrooms: All bathrooms have a working toilet, wash basin, bathtub/shower. CONTINUED ON LIC809-C

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: CALIFORNIA HOME CARE	FACILITY NUMBER: 306006022
	VISIT DATE: 08/30/2021

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
26
27
28
29
30
31
32

Linens & Hygiene Supplies:
Adequate supply of linens is stored in hall closet.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review in the kitchen.

Food Service:
Adequate supply of 7-day non-perishable and 2-day perishables are stored in the kitchen with surplus goods stored in the garage.

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

Fire Clearance:
Was approved on 07/07/21.

Appliances:
Gas four-burner stove, single oven, refrigerator, microwave, dish washer, an additional refrigerators in attached garage, washer, and dryer are clean and noted to be operational.

Toxins:
Locked/stored in a cabinet located in the attached garage.

Water Temperature:
Tested and recorded at 113 degrees Fahrenheit in bathrooms.

Medications, First-Aid Kit & Book:
First aid is stored in medication storage closet. Medication will be stored in locked storage closet.

CONTINUED ON LIC809-C

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: CALIFORNIA HOME CARE	FACILITY NUMBER: 306006022
	VISIT DATE: 08/30/2021

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
26
27
28
29
30
31
32

Clients & Staff Files:
Records will be kept locked in storage cabinet in living room.

Reading Material, Games, Equipment & Materials:
The facility has activities that commensurate with their plan of operation.

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

Applicant was reminded that it is required to notify LPA, within 5 business days of admitting the first client. This notification may be done by phone, email or fax.

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.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3