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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006033
Report Date: 11/09/2021
Date Signed: 11/09/2021 11:43:59 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:CITRINE RESIDENTIAL CAREFACILITY NUMBER:
306006033
ADMINISTRATOR:CELIS, PRISCILLAFACILITY TYPE:
740
ADDRESS:3359 W ORANGE AVETELEPHONE:
(949) 573-6489
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 5DATE:
11/09/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Priscilla Celis, ApplicantTIME COMPLETED:
12:00 PM
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Licensing Program Analyst, Kathrina Chin made an unannounced visit for a pre-licensing evaluation. LPA met with Priscilla Celis, Applicant. The facility has five bedrooms and three bathrooms and is a single story with a two car garage. The inspection is as follows:

A fire clearance was granted on October 19, 2021 for one (1) ambulatory and five ( 5) non-ambulatory. The facility has submitted a hospice waiver request for 5 residents.

LPA toured the facility, interior and exterior, including all resident bedrooms. Hot water were tested in a bathroom and observed to be 106 degrees Fahrenheit. Fire extinguishers were mounted and charged. Smoke detectors were centrally wired throughout and have been checked by the fire department. Carbon monoxide detectors are operational. There is a sufficient supply of linens. Bedrooms are appropriately furnished. There is sufficient lighting. There are non-skid mats in the showers.

There was one locked medication closet which stores one first aid kit. There were several locked closets for storage of toxins, cleaning equipment and PPEs in the garage. All exit has auditory devices. The kitchen area was checked and there is a sufficient supply of food items. There were emergency food supplies and water. LPA observed activity calendars, menu, theft and loss policy, residents rights, admission agreement, and emergency plans were posted including the Let Us Know poster. LPA reviewed the outdoor area and with outdoor furniture with an umbrella for shade.

The Component III Orientation is waived as Priscilla Celis is an existing facility operator. (Continued on LIC 809-C)
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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: CITRINE RESIDENTIAL CARE
FACILITY NUMBER: 306006033
VISIT DATE: 11/09/2021
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It appears that this facility meets the requirements for licensure. Both the license and the hospice waiver will be granted upon final review and approval from the Central Applications Bureau.

An exit interview was conducted with Priscilla Celis, Applicant and a hard copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC809 (FAS) - (06/04)
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