306006118-4-17-2023-22-AS-RMAZ-CQYS82-20230417133825

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006118
Report Date: 04/17/2023
Date Signed: 04/17/2023 01:38:36 PM

Document Has Been Signed on 04/17/2023 01:38 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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	HILLS OF SHAY DEL, THE		FACILITY NUMBER:	306006118
ADMINISTRATOR:	NEPOMUCENO, MARICEL		FACILITY TYPE:	740
ADDRESS:	5982 SHAY DEL PLACE		TELEPHONE:	(626) 827-9547
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92870
CAPACITY:	6	CENSUS:	DATE:	04/17/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Maricel Nepomuceno		TIME COMPLETED:	11:40 AM

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) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at facility was greeted and granted entry. LPA met with Maricel Nepomuceno, Administrator and explained the visit. An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden resident was submitted to CCL on 10/28/21. Structure: The facility is a one story house with an attached garage with 5 resident bedrooms, 3 full bathrooms, 2 living rooms, a dining room, and a kitchen. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with a closed patio and one exit walkway on one side of the house with seating for the residents. Air/Heating: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms will accommodate 6 residents with 4 private rooms and 1 shared room accommodating two residents. Bedrooms 4 has a full bathroom. Continued on LIC809-C

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023

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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HILLS OF SHAY DEL, THE	FACILITY NUMBER: 306006118
	VISIT DATE: 04/17/2023

NARRATIVE

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Bedrooms Staff:
Designated bedroom for live-in staff.

Bathrooms:
Facility has three full bathrooms. All bathrooms have a working toilet, wash basin, walk in shower.

Linens & Hygiene Supplies:
Adequate supply of linen in closet storage in main living room.

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 and available. Menus prepared one week prior and listed for food serve for one week.

Food Service:
Adequate supply of 7-day non-perishable and 2-day perishables are stored in the kitchen with surplus goods stored in garage.

Smoke Detectors:
Smoke detectors and carbon monoxide alert systems are hardwired, were tested, and found operational. 2 fire extinguishers mounted in kitchen and resident bedroom hallway charged and dated 7/11/22.

Appliances:
Gas five burner stove, single oven, 2 refrigerator (kitchen and garage), freezer (garage), microwave, dishwasher, washer, and dryer are clean and noted to be operational.

Toxins:
All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are stored and locked underneath kitchen sink, laundry unit and garage.

Continued on LIC809-C

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023

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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HILLS OF SHAY DEL, THE	FACILITY NUMBER: 306006118
	VISIT DATE: 04/17/2023

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Water Temperature:
Tested and recorded maintained at a comfortable temperature and the water temperature measures 116.9 Fahrenheit degrees in facility bathrooms.

Medications, First-Aid Kit & Book:
Medication and First Aid kit stored in locked storage cabinet in second living room.

Resident & Staff Files:
Records will be kept locked in with medication storage.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the resident's use, commensurate with the plan of operation.
Fire clearance:
Was approved on 03/15/23

Component III:
Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities.

Facility appears to be ready for licensure. Accordingly, LPA will submit file for approval to CCL Supervisor. Exit interview was conducted and a copy of this report was left with the applicant.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023

LIC809 (FAS) - (06/04)

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