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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006116
Report Date: 03/30/2022
Date Signed: 03/30/2022 10:05:44 AM


Document Has Been Signed on 03/30/2022 10:05 AM - 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:
03/30/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jonathan MartinezTIME COMPLETED:
10:20 AM
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Licensing Program Analysts (LPA) Kimberly Lyman and Andrea Mendivil made an announced visit to follow up on a pre-licensing inspection conducted on 03/10/2022. 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.

At 9:37 AM, LPAs toured the facility and observed the following:
  • Facility has covid pre-caution postings in the entrance of the facility.
  • Bricks have been removed from the entry path.
  • Facility has implemented a covid screening station in the entrance of facility with a sign in sheet/ questionnaire.
  • Facility has posted the "Let Us No" poster in regulation size.
  • Hand washing signs are posted in the restrooms.
  • Water temperature tested between 109 and 111 degrees F in facility restrooms.
  • Common restroom has been re-painted.
  • Bed frames have been obtained for beds in room #2.
  • Facility has ample supply of drink ware and bowels.
  • Facility has ample supply of PPE on-site.
  • Facility has shaded outdoor seating in the backyard.
  • Facility has a secured area for sharps and toxins.


Facility is ready to be licensed. 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: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
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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