306006047-12-8-2021-22-AS-KLYN-C9GR8J-20211207114802

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006047
Report Date: 12/07/2021
Date Signed: 12/08/2021 07:22:49 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:	KNOTT'S LANDING LUXURY CARE		FACILITY NUMBER:	306006047
ADMINISTRATOR:	RAJPOOT, FAISAL		FACILITY TYPE:	740
ADDRESS:	6359 ARNOLD WAY		TELEPHONE:	(949) 290-1826
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY:	6	CENSUS:	DATE:	12/07/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kamil Rajpoot and Faisal Rajpoot		TIME COMPLETED:	12:10 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 Analysts (LPAs) Kimberly Lyman and Kevin Saborit-Guasch made an announced visit to conduct a pre-licensing inspection. LPAs identified themselves and discussed the purpose of the visit with Administrator/ Licensee Faisal Rajpoot. Facility Manager Kamil Rajpoot was present as well. An initial application to operate a Residential Care Facility for the Elderly was received by CCL on 08/09/2021 for a capacity of six non-ambulatory residents. Administrator Faisal Rajpoot has an administrator certificate expiring on 03/10/2022. LPA Lyman and Saborit-Guasch along with Administrator and Facility Manager toured the facility at 10:13 AM and observed the following: Structure: Facility is a one story, 4 bedroom, 2 bathroom house with an attached garage and a tan exterior. The exit gates are closed, unlocked, and self latching. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: Rooms will be a mix of single and double occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Linens & Hygiene Supplies: Linen supply is in ample supply for residents in care. Emergency Phone Numbers and Exit Plan: Available for review in the entrance area of the facility. Food Service: Facility has ample 2 day perishables as well as 7 day non-perishables in the pantry. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguishers are charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: Locked/stored in the secured garage. Facility to obtain another lock for an additional cupboard in kitchen. Water Temperature: Tested and recorded at 130 degrees F. in facility bathrooms. Emergency Supplies: LPAs observed ample emergency food and water. CONT ON LIC 809C DATED 12/07/2021..

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021

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: KNOTT'S LANDING LUXURY CARE	FACILITY NUMBER: 306006047
	VISIT DATE: 12/07/2021

NARRATIVE

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Medications, First-Aid Kit & Book: First aid kit observed contained all required items. LPA observed completed emergency disaster plan. Medication to be stored and locked in a locked cabinet in the kitchen. Facility uses a medication administration record. Resident & Staff File: Records to be are stored in a cupboard in the living room. Reading Material, Games, and Equipment: Facility to provide activities depending on resident's choice. Backyard: LPA observed a clean backyard with ample shaded seating for residents. Fire Clearance: Approved for 6 non-ambulatory residents on 11/16/2021.

Licensee to address the following and forward proof to LPA by 12/21/2021:

Please adjust water temperature to be between 105 and 120 degrees F.
Please repair/ remove bricks on side yard.
Please remove wood in backyard as well as trash bags and construction items from front yard
Please maintain a thirty day supply of PPE on-site at the facility at all times.
Please repair/ replace closet door in bedroom.
Please enlarge the "Let Us No" sign to regulation size 20" X 26."
Please post activity schedule and sample menu

Component III was conducted during this visit as well.

The facility is not ready to be licensed. Licensee to notify LPA when corrections are completed.

An exit interview was conducted with Administrator and Facility Manager and a copy of this report was provided to Administrator.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021

LIC809 (FAS) - (06/04)

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