306006128-3-30-2022-22-AS-RMAZ-CCZQ3R-20220330114910

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006128
Report Date: 03/30/2022
Date Signed: 03/30/2022 11:49:29 AM

Document Has Been Signed on 03/30/2022 11:49 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:	VILLAS BY DOCTOR ROYA		FACILITY NUMBER:	306006128
ADMINISTRATOR:	JAFARI-HASSAD, ROYA		FACILITY TYPE:	740
ADDRESS:	23232 LA VACA ST		TELEPHONE:	(516) 322-3095
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 0	DATE:	03/30/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Roya Jafari-Hassad		TIME COMPLETED:	12:55 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 Analysts (LPAs) Ruth Martinez and LPA Celine De Perio conducted announced visit to the facility for purpose of a pre-licensing evaluation. LPAs arrived to the facility was greeted by applicant and granted entry. 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 clients was submitted to CCL on 12/23/2021. Structure: The facility is a one-story house with an attached garage with 6 bedrooms, 3 bathrooms, 1 living room, 1 dining room, and a restaurant style open kitchen. The residents bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with an exit way on each side of the house with shaded seating area for residents. Signal system: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms are for 5 non-ambulatory and 1 bedridden. Bedrooms will accommodate 6 residents with all rooms being private. Bedrooms Staff: No bedroom due to no live in staff. Continued on LIC809-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
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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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: VILLAS BY DOCTOR ROYA	FACILITY NUMBER: 306006128
	VISIT DATE: 03/30/2022

NARRATIVE

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Bathrooms:
All bathrooms have a working toilet, wash basin, bath-tub/shower.

Linens & Hygiene Supplies:
Adequate supply of linen stored in storage cabinets throughout the facility.

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 to be stored in the kitchen with surplus goods stored in the attached garage.

Smoke Detectors:
Smoke detectors and carbon monoxide alert systems are hardwired, were tested and found operational.

Appliances:
Gas six-burner stove, single oven, 2 refrigerator/freezer, dish washer, microwave, washer, and dryer are clean and noted to be operational.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents are stored and locked in a storage unit in the kitchen.

Water Temperature:
Tested and found that there is no hot water being delivered.

Continued on LIC809-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
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

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: VILLAS BY DOCTOR ROYA	FACILITY NUMBER: 306006128
	VISIT DATE: 03/30/2022

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Medications, First-Aid Kit & Book:
Medication stored in storage unit locked inaccessible to residents.

Clients & Staff Files:
Records will be kept locked in storage unit located in kitchen.

Pool/Jacuzzi & Pets:
No bodies of water in facility.

Fire Extinguisher:
Mounted on wall.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation.

Fire clearance:
Was approved on January 18, 2022.

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

The following items must be completed prior to licensure:

1. The water heater needs to be in working condition to deliver hot water.

Any items noted above are to be corrected and LPA Martinez is to be notified to conduct a inspection visit to verify items have been corrected and in good repair.

This report was reviewed with applicant and a copy was provided to applicant.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
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

LIC809 (FAS) - (06/04)

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