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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006049
Report Date: 07/26/2024
Date Signed: 07/26/2024 02:37:10 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/26/2024 02:37 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CARE ADDISON LLCFACILITY NUMBER:
306006049
ADMINISTRATOR/
DIRECTOR:		FISCHER, LONNIEFACILITY TYPE:
740
ADDRESS:207 BAGNALL AVE.TELEPHONE:
(714) 393-2308
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 0DATE:
07/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Administrator, Lonnie FischerTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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On 7/26/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA rang the doorbell and knocked at the front door and did not receive a response. LPA called Administrator, Lonnie Fischer and informed them of the purpose of the visit. Administrator Fischer reported the home is vacant pending approval of the Assisted Living Waiver Program and they were available to meet with LPA to grant them entry into the facility. The facility has a fire clearance for six (6) non-ambulatory elderly residents, of which one (1) may be bedridden.

Administrator Fischer arrived to the facility and granted LPA entry into the home. LPA toured the facility with Administrator Fischer and observed the facility is made up of a one-story home with four (4) resident bedrooms, three (3) bathrooms, a staff room, kitchen, dining room, living room and attached garage. During the tour, LPA did not observe any residents in care or evidence to suggest the home is currently occupied by residents. Administrator Fischer tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed charged fire extinguishers mounted throughout the facility. There is plenty of storage room for perishable and non-perishable foods along with a working refrigerator and stove available for future resident placement. Medications will be secured in a locked kitchen cabinet. Indoor and outdoor passageways were free of obstruction. No bodies of water were observed on the premises. Resident bedrooms had the required furniture and lighting. Bathrooms had grab bars near the toilets and in the showers. Administrator Fischer was advised to contact the Orange County Regional Office to inform them when residents are placed in the facility.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted where this report was reviewed and provided to Administrator Fischer.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
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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