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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006034
Report Date: 10/14/2021
Date Signed: 10/15/2021 09:52:07 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:PHAMILY HOME ELDERLY CARE 2FACILITY NUMBER:
306006034
ADMINISTRATOR:PHAM, CHARLESFACILITY TYPE:
740
ADDRESS:16652 HUGGINS AVETELEPHONE:
(657) 724-9930
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 0DATE:
10/14/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Charles Pham, AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analysts, Kathrina Chin and Beverly Thompson-Gracia made an unannounced visit for a pre-licensing evaluation. LPAs met with Charles Pham, Administrator. The facility has four bedrooms and two and a half bathrooms and is a single story with a two car garage. The inspection is as follows:

A fire clearance was granted on July 28, 2021 for 6 non-ambulatory of which one may be bedridden. This facility has submitted a hospice waiver request for 1 resident.

LPAs 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 two first aid kits. There were several locked closets for storage of toxins, cleaning equipment, 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, theft and loss policy, residents rights, admission agreement, and emergency plans were posted including the Ombudsman and Let Us Know posters. LPA reviewed the outdoor area and with outdoor furniture.

A Component III was completed during the visit with Charles Pham, Administrator. LPAs reviewed Personnel Policies, Prohibited Health Conditions, Fingerprinting, Abuse Reporting Procedures, In-Service Training and Medication Procedures. (Continued LIC 9099C)
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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: PHAMILY HOME ELDERLY CARE 2
FACILITY NUMBER: 306006034
VISIT DATE: 10/14/2021
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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 Administrator, Charles Pham 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: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC809 (FAS) - (06/04)
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