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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006074
Report Date: 05/12/2022
Date Signed: 05/12/2022 03:51:51 PM

Document Has Been Signed on 05/12/2022 03:51 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:SUCCESSFUL PEOPLE LLC #5FACILITY NUMBER:
306006074
ADMINISTRATOR:SNODDY, FRANCESFACILITY TYPE:
735
ADDRESS:1774 W CHALET AVETELEPHONE:
(310) 902-4893
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 4CENSUS: 0DATE:
05/12/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Frances Snoddy - Administrator TIME COMPLETED:
04:05 PM
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Licensing Program Analysts (LPAs) Patricia Velazquez, Edward Tapia and Andrea Mendivil conducted an announced Pre-Licensing visit with Component III Orientation to Successful People LLC #5. LPAs conducted the visit with Administrator Frances Snoddy. An initial application to operate a Adult Residential Facility (ARF) was submitted to the Central Applications Bureau (CAB) on 04/12/2022 for a capacity of 4 non-ambulatory clients .

LPAs Velazquez, Tapia, Mendivil along with Administrator Snoddy observed the following:


Structure:
Facility is a one story house with 4 resident bedrooms, an office, 3 bathrooms, living room, dining area, and kitchen. The facility has a beige stucco exterior with white and orange trim. There is a 2 car attached garage, that houses a washer and dryer. There is a front yard comprised of grass and paved drive way. The backyard has a shaded concrete area with seating for clients as well as a large grassy area with trees and plants. The exit gates on the exterior of the home had self-closing and self-latching mechanisms which were operating properly.
Signal System:
The facility's central heating and air conditioning is controlled by a thermostat located in the hallway.
Bedrooms Clients :
All bedrooms accommodate ambulatory clients with bedroom Emergency flashlights were present in the facility. The clients bedrooms accommodate the clients ' furnishings.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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: SUCCESSFUL PEOPLE LLC #5
FACILITY NUMBER: 306006074
VISIT DATE: 05/12/2022
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Bathrooms:
All bathrooms have a working toilet, wash basin, and walk-in shower. Grab bars were present as a well as a non-skid mat or surface.
Linens and Hygiene Supplies:
Adequate supply of linens and hygiene supplies were located in a linen cabinet in a bathroom as well as the client rooms.
Appliances: Refrigerator, dish washer, washer and dryer, microwave, induction stove top with oven
Emergency Phone Numbers, Exit Plan:
Readily available for review in the entry area of the facility.
Postings:
The Complaint poster will be posted in the entry area of the facility. Coronavirus (COVID-19) documents were observed in a binder and will be posted throughout the facility.
Food Service and Menu:
There was an adequate supply of 7 day non-perishable and 2 day perishables present in the facility. The sample menu was available for review.
Smoke and Carbon Monoxide Detectors:
Smoke detector and Carbon Monoxide alert systems were interconnected tested and found operational.
Fire Extinguisher:
Fully charged and mounted on a wall in the entry way. Approved 03/14/2022 for 4 non-ambulatory clients.
Fire Clearance:
Approved on 03/14/2022 for 4 non-ambulatory.
Toxins and Sharps:
The cleaning supplies were locked and stored in a cabinet underneath the sink in the kitchen. The knives and other sharp items will stored in a locked closet in the office.
Water Temperature:
Tested and recorded at 111.5 degrees Fahrenheit in bathroom 1, at 106.1 degrees Fahrenheit in bathroom 2, and at 109.5 degrees Fahrenheit in bathroom 3.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
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: SUCCESSFUL PEOPLE LLC #5
FACILITY NUMBER: 306006074
VISIT DATE: 05/12/2022
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Medications, First Aid Kit & Manual:
First Aid kit with manual were stored in a container located in the garage. It will be stored in a locked closet located in the office. Medication will be stored in a locked closet located in the office. Resident and Staff Files: Resident and staff records will be stored in a locked closet located in the office.

Reading Material, Games, Equipment, & Materials:


The facility had materials, games, and equipment present in the facility that commensurate with their plan of operation.

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



The Pre-Licensing is complete and this facility has no deficiencies. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau.

An exit interview was conducted with Administrator Frances Snoddy and a copy of this report was provided at the time of this visit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
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