306006067-8-15-2022-22-AS-JALE-CHBV67-20220815160903

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006067
Report Date: 08/15/2022
Date Signed: 08/15/2022 04:09:12 PM

Document Has Been Signed on 08/15/2022 04:09 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:	FAITH HOME CARE, LLC		FACILITY NUMBER:	306006067
ADMINISTRATOR:	TECSON, ALEXANDER		FACILITY TYPE:	735
ADDRESS:	2367 W HANSEN ST.		TELEPHONE:	(714) 496-1732
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY: 6		CENSUS: 0	DATE:	08/15/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Alexander Tecson		TIME COMPLETED:	04:31 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) Joseph Alejandre made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility and was greeted and granted entry by Applicant Purita Ramos. Administrator Alexander Tecson was also present. An application to operate an Adult Residential Facility for, 4 ambulatory clients was submitted to CCL on August 9, 2021. Structure: The facility is a two story home with 5 bedrooms, 1 bedroom which will be used for staff is on the second floor and has its own bathroom, 3 bathrooms, living room, dining room, family room, kitchen, laundry room and a 2 car garage. Facility telephone phone number is 657-201-3823. LPA observed the See Something, Say Something poster (PUB 475) by the front door of the facility. LPA observed there is no door alarm on the front door. There is a back yard with 1 exit gate on the side of the house. The exit gate is not alarmed and is not self closing. The exit gate is operational. There is a shaded seating area in the backyard. No bodies of water observed in the backyard. No obstacles or hazards observed inside or outside of the facility. Client Bedrooms All four of the client’s bedrooms are spacious and will easily accommodate the resident’s belongings. All client bedrooms had the required furnishings. Each client will have a private room. Signal system There is no signal system.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

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: FAITH HOME CARE, LLC	FACILITY NUMBER: 306006067
	VISIT DATE: 08/15/2022

NARRATIVE

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Bedrooms Staff:
The master bedroom on the second floor will be used for the live in staff. The bedroom has it's own bathroom. No deficiencies observed in the master bedroom. The master bedroom door has a lock and the Administrator reported it will be kept locked.

Bathrooms:
All bathrooms are operational and clean. Hot water measured 120.0 degrees Fahrenheit in all three bathrooms. All showers had no slip mats.

Linens & Hygiene Supplies:
Adequate supply of linen stored in the hallway storage upstairs.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted in the dining room.

Food Service:
LPA the facility observed a two day supply of perishable food and a seven day supply of non-perishable food on hand in the kitchen. LPA observed emergency food stored in a plastic container in the dining room.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas four burner stove with 1 oven, 1 refrigerator, dish washer, microwave, washer, and dryer are clean and operational.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

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: FAITH HOME CARE, LLC	FACILITY NUMBER: 306006067
	VISIT DATE: 08/15/2022

NARRATIVE

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Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and will be stored under the kitchen sink and in the garage.

Medications, First-Aid Kit & First Aid Booklet:
Medication will be stored in a locked cabinet in the family room. The First aid kit is stored with the medication. The First aid kit has all the required elements.

Resident & Staff Files:
Records will be kept locked in the medication cabinet.

Pool/Jacuzzi & Pets:
No bodies of water in facility. There will be no pets at the facility.

Fire Extinguisher:
All fire extinguishers are fully charged.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the client’s use, stored in the family room.

Fire clearance:
Was approved by fire inspector Alicia Badosa from the Anaheim Fire Department on 4/06/2022.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance and reporting requirements.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: FAITH HOME CARE, LLC	FACILITY NUMBER: 306006067
	VISIT DATE: 08/15/2022

NARRATIVE

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Applicant was reminded that it is required to notify LPA, when they receive their first client. This notification may be done by phone, email or fax. Accordingly, applicant was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. LPA informed the applicant that once the facility is licensed a post licensing visit will be conducted within 90 days of licensure.

No deficiencies observed at the facility. No corrections are required. LPA informed the applicants the physical plant is ready to accept residents. The facility is now ready to be licensed. An exit interview was conducted and a copy of the report provided.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

LIC809 (FAS) - (06/04)

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