306006029-10-28-2021-22-AS-RMAZ-C88Q2D-20211028114659

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006029
Report Date: 10/28/2021
Date Signed: 10/28/2021 11:47:13 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:	JADE RESIDENTIAL CARE		FACILITY NUMBER:	306006029
ADMINISTRATOR:	CELIS, PRISCILLA		FACILITY TYPE:	740
ADDRESS:	11821 FLAMINGO DR.		TELEPHONE:	(949) 573-6489
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY:	6	CENSUS: 6	DATE:	10/28/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Priscilla Celis, Administrator		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 and announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at the facility was greeted and granted entry by Administrator. 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 06/18/2021. Structure: The facility is a one-story house with an attached garage with 4 resident bedrooms, 1 caregiver bedroom, 1 living room, 1 dining room, and a restaurant style open kitchen, and 2 full bathrooms. 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: 4 Bedrooms are for 6 non-ambulatory residents. Bedrooms will accommodate 6 residents with 1 room being private rooms and 3 shared room. 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: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

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: JADE RESIDENTIAL CARE	FACILITY NUMBER: 306006029
	VISIT DATE: 10/28/2021

NARRATIVE

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Bedrooms Staff:
1 bedroom will be for live in staff.

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

Linens & Hygiene Supplies:
Adequate supply of linen stored in hallway storage.

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:
Electric four-burner stove, single oven, 1 refrigerator/freezer, dish washer, microwave, washer, dryer, and a spare refrigerator in garage 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 in attached garage.

Water Temperature:
Tested and recorded the water temperature measures 114.8 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: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

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: JADE RESIDENTIAL CARE	FACILITY NUMBER: 306006029
	VISIT DATE: 10/28/2021

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Medications, First-Aid Kit & Book:
Medication stored in storage cabinet with lock in kitchen inaccessible to residents. First aid kits are stored and located in office storage cabinet.

Resident & Staff Files:
Records will be kept locked in storage closet in office space.

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

Fire Extinguisher:
Mounted in wall in kitchen and entry way of office dated April 14, 2021.

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

Fire clearance:
Was approved on 09/15/2021.

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

All items reviewed during this 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 with Administrator and a copy of this report was left at facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

LIC809 (FAS) - (06/04)

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