306006039-9-17-2021-22-AS-SHAD-C6XPQL-20210917113119

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006039
Report Date: 09/17/2021
Date Signed: 09/17/2021 11:31:29 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:	TRADITIONS AT LUCERO WAY		FACILITY NUMBER:	306006039
ADMINISTRATOR:	REYES, LORDELE DE LOS		FACILITY TYPE:	740
ADDRESS:	17801 LUCERO WAY		TELEPHONE:	(714) 769-5858
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY:	6	CENSUS: 0	DATE:	09/17/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Lordele De Los Reyes		TIME COMPLETED:	11:30 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) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Administrator (AD) Lordele De Los Reyes, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 07/14/2021. This is a change of ownership with no persons in care. During the inspection, LPA and AD observed the following: Structure. This is a one-story home. Facility is a 7-bedroom, 4-bathroom, 1 story house with attached garage that is being used for storage. There is a back yard with a patio cover for the clients. Facility telephone number is (714) 617-5292. Bedrooms Residents. The 6 client bedrooms are spacious and will easily accommodate the client's furnishings. Lamps, chairs, linens, and storage for each client bedroom inspected. Bedrooms staff. The 1 staff bedroom is spacious and will easily accommodate the staff's furnishings. Lamps, chairs, linens, and storage for the staff bedroom inspected. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 110 to 115 F degrees. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. 7 days nonperishable food supply reviewed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detector/carbon monoxide detector. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen cabinet. Toxins: observed locked under the sink and in a garage closet. Medication cabinet is locked. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files. This is an initial inspection, LPA reviewed resident and staff storage area. Fire clearance was approved by Orange County Fire Authority Inspector Ryan Ferdia on 08/03/2021. Backyard. Backyard exit gate is operational and unlocked. Backyard has shaded area for outdoor activities and sufficient seating for residents.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

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: TRADITIONS AT LUCERO WAY	FACILITY NUMBER: 306006039
	VISIT DATE: 09/17/2021

NARRATIVE

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Component III was completed with AD during today’s inspection. During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AD was informed today that the facility is ready for licensure and final approval will be processed by the Centralized Applications Bureau supervisor in Sacramento. An exit interview was conducted and a copy of this report was discussed with and provided to AD.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

LIC809 (FAS) - (06/04)

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