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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006049
Report Date: 10/05/2021
Date Signed: 10/05/2021 04:34:18 PM

Document Has Been Signed on 10/05/2021 04:34 PM - It Cannot Be Edited

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:CARE ADDISON, LLCFACILITY NUMBER:
306006049
ADMINISTRATOR:FISCHER, LONNIEFACILITY TYPE:
735
ADDRESS:207 BAGNALL AVE.TELEPHONE:
(714) 393-2308
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 0DATE:
10/05/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Lonnie FischerTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Norman Woodridge conducted this announced inspection for the purpose of conducting a Pre-licensing inspection. LPA met with Administrator (AD) Lonnie Fischer, discussed the purpose of the inspection, and toured the facility. Facility is to operate as a Residential Care for the Elderly (RCFE) facility.

LPA and AD toured the facility and observed the following. This is a one-story home with 5-bedrooms, 2-bathrooms, and a garage. Four of the bedrooms will be used for residents and one bedroom will be used as a staff bedroom. There is an outside shade for tools which can be locked. The telephone number for the facility is (714) 463-4599. The facility email address is Lonniefischer@sbcglobal.net. The four client bedrooms did not have beds or linen. The restrooms did not have hand soap, paper towels or hand sanitizer. Water temperature: tested between 105.9 to 107.1 F degrees. LPA observed knives that were locked. LPA observed a locked area where medication will be stored. LPA reviewed fire clearance and exit plan. Facility did not have 2-day supply of perishable food or 7-day nonperishable food supply. LPA observed working Carbon Monoxide, Smoke Detectors, and Fire Extinguishers. LPA observed appliances including a stove, microwave, and refrigerator. LPA observed First-Aid Kit & Activity Supplies. Fire clearance was approved by the Placentia Fire Department Inspector J. Van Gieson on September 8, 2021. RO will waive COMP III due to facility already being in operation at a different location.

The license will be approved; however, the following items must be corrected: The garage must be cleared of debris and a wash machine along with a dryer must be placed in the garage. Broken light fixture in resident bedroom number 5 must be repaired. Items must be stored away including toxins, chemicals, and cleaning products. Door in staff bedroom must be fixed and items obstructing the walkways must be removed. Beds with clean lining must be placed in bedrooms and the facility must store clean linen for residents.

Licensee will provide proof of corrections by C.O.B. October 6, 2021.

SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Norman Woodridge
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2021
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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