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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006116
Report Date: 03/10/2022
Date Signed: 03/10/2022 03:28:06 PM


Document Has Been Signed on 03/10/2022 03:28 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:FLOWERS FAMILY CAREFACILITY NUMBER:
306006116
ADMINISTRATOR:MARTINEZ, JONATHANFACILITY TYPE:
740
ADDRESS:1009 W 20TH ST.TELEPHONE:
(949) 274-0634
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY:6CENSUS: 0DATE:
03/10/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jonathan MartinezTIME COMPLETED:
11:35 AM
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Licensing Program Analysts (LPA) Kimberly Lyman and Andrea Mendivil made an announced visit to conduct a pre-licensing inspection. LPAs identified themselves and discussed the purpose of the visit with Administrator/ Licensee Jonathan Martinez. An initial application to operate a Residential Care Facility for the Elderly was received by CCL on 02/17/2022 for a capacity of five non-ambulatory residents and one bedridden. Facility does not have a screening area in the entrance of the facility and LPAs were not screened upon entry. LPAs observed no covid signage at entrance to facility as well as none posted in residence. LPAs observed no supply of PPE.
LPAs Lyman and Mendivil along with Licensee/ Administrator toured the facility at 9:10 AM and observed the following:
Structure: Facility is a one story, 3 bedroom, 2 bathroom house with a detached garage and a red exterior. The exit gate is unlocked and self latching. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: Rooms will be double occupancy. All of the rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Facility has sanitizer and paper towels in the restrooms. Linens & Hygiene Supplies: Facility has bedding and towels for residents in care. Emergency Phone Numbers and Exit Plan: Posted in entrance of facility. Food Service: Facility has no food present during visit. Licensee will obtain 2 day perishable and 7-day nonperishable foods prior to accepting residents.. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguisher is mounted and charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: LPA's did not observe a secure area for sharps or toxins. Water Temperature: LPAs were unable to test hot water as it was not working at this time. . Emergency Supplies: LPAs observed no emergency food or water and disaster plan was posted in entrance. Medications, First-Aid Kit & Book: First aid kit observed contained all required items. CONTINUED ON LIC 809C DATED 03/10/2022
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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: FLOWERS FAMILY CARE
FACILITY NUMBER: 306006116
VISIT DATE: 03/10/2022
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Medication to be stored and locked in a locked cabinet in the kitchen. Facility to use a medication administration record. Resident & Staff File: Records to be are stored in a locked cabinet.. Reading Material, Games, and Equipment: Licensee does not have an activity schedule but will post prior to accepting residents. LPAs observed games and books in facility. Backyard: LPA observed 2 chairs for outdoor seating and a pool secured with a fence. Fire Clearance: Approved for five non-ambulatory residents and one bedridden resident on 02/11/2022.

Licensee to address the following items and contact LPA when completed:
  • Please post covid pre-caution signage outside facility entrance.
  • Please remove bricks in entry which pose a safety risk.
  • Please implement a screening/ sanitizing station in entrance of facility including a sign in sheet and health questionnaire.
  • Please post the "Let Us No" poster in the entrance of facility in regulation size, 20"X 26"
  • Please post hand washing signs in facility restrooms.
  • Please ensure water temperature is between 105 and 120 degrees F.
  • Please repair/ re-paint discolored areas in shared restroom.
  • Please obtain bed frames for beds in room 2.
  • Please ensure an ample supply of drink ware and bowls are stored in the facility.
  • Please obtain a thirty day supply of PPE on-site at all times.
  • Please obtain emergency food and water for facility.
  • Please ensure there is ample shaded, outdoor seating for all residents.
  • Please maintain a secured area for sharps and cleaning supplies.




Component III conducted during the visit. Facility is not ready to be licensed. Licensee to contact LPA when corrections have been made.


Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC809 (FAS) - (06/04)
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