306006062-10-25-2021-22-AS-SFRK-C85TZS-20211025151045

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006062
Report Date: 10/22/2021
Date Signed: 10/25/2021 03:11:33 PM

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:	JADE GUEST HOME		FACILITY NUMBER:	306006062
ADMINISTRATOR:	DAO, BREVET		FACILITY TYPE:	740
ADDRESS:	2710 N. BERKELEY ST		TELEPHONE:	(714) 507-8040
CITY:	ORANGE	STATE: CA	ZIP CODE:	92880
CAPACITY:	6	CENSUS: 6	DATE:	10/22/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:57 AM
MET WITH:	Licensee Brevet Dao		TIME COMPLETED:	02:20 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 Analyst (LPA) Shobhana conducted announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Licensee Brevet Dao 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 05/27/2021. This is a change of ownership. LPA observed COVID - visitation station equipped with hand sanitizer, thermometer, Gloves, visitors log, COVID posters throughout the facility. All staff and resident are vaccinated. Every two week the facility conduct COVID testing for staff. LPA observe the facility to be clean and in good repair. Physical Plant and Safety of Environment/Operational as CCL Requirements. During the inspection, LPA observed the following. Structure. This is a one-story home. Facility is a 4 bedroom- 2- bathroom, 1 story house with attached garage that is being used for storage. There is a back yard with a patio cover for the residents . Facility telephone number is (657) 223-9641. Bedrooms Residents. The 6 residents bedrooms are spacious and will easily accommodate the client's furnishings. Lamps, chairs, linens, and storage for each residents bedroom inspected. Bedrooms staff. The 1 staff bedroom is spacious and will easily accommodate the staff’s furnishings. Lamps, chairs, linens, and storage for each staff bedroom inspected. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested 114 F degrees. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. 2 days perishable and 7 days nonperishable food supply observed. 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/stored in the kitchen cabinet. Toxins: observed in the locked cabinet in the

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

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: JADE GUEST HOME	FACILITY NUMBER: 306006062
	VISIT DATE: 10/22/2021

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garage. Medication cabinet is locked. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files. LPA reviewed resident and staff files. Fire clearance was approved by Orange County Fire Authority . Backyard. Backyard exit gate is operational and unlocked. Backyard has shaded area for outdoor activities and sufficient seating for residents. Component III was completed with AD during today’s inspection. Facility is currently operating under the liability insurance of current facility DJ Guest Home (306005335). Licensee will switch liability insurance to new facility once the application is approved.

During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. Licensure was informed today that the facility is ready for licensure and final approval will be processed by the CAU supervisor in Sacramento. An exit interview was conducted and a copy of this report was discussed with and provided to Licensure.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

LIC809 (FAS) - (06/04)

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