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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006132
Report Date: 03/24/2022
Date Signed: 03/24/2022 11:03:33 AM

Document Has Been Signed on 03/24/2022 11:03 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:BEVERLY HOMEFACILITY NUMBER:
306006132
ADMINISTRATOR:CHEA, PAULFACILITY TYPE:
735
ADDRESS:1183 W. CHATEAU AVETELEPHONE:
(714) 537-6530
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: 0DATE:
03/24/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Paul CheaTIME COMPLETED:
11:17 AM
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Licensing Program Analysts (LPAs) Sean Haddad and Claudia Gutierrez conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPAs met with Administrator (AD) Paul Chea, discussed the purpose of the inspection, and toured the facility. Facility is to operate an Adult Residential Facility. Application was submitted to Community Care Licensing on 01/03/2022. This is a Change of Location from BEVERLY HOME (306004725) 9811 Beverly Lane, Garden Grove, CA 92841.

During the inspection, LPAs and AD observed the following: Structure. This is a one-story home. Facility is a 4-bedroom, 2-bathroom, 1 story house with attached garage that is being used for storage. There is a back yard with a patio cover for the clients. AD stated they will add additional shade and outdoor furniture for the clients. Facility telephone number is (714) 537-6530. Client Bedrooms. The 4 client bedrooms are spacious and will easily accommodate the client's furnishings. Lamps, chairs, linens, and storage for each client bedroom will be relocated the same day as the clients when the change of location has been approved. Bedrooms staff. This facility has no staff bedrooms. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 115 to 116.6 F degrees. Linens & Hygiene Supplies. Linen closets were observed. Linens will be relocated the same day as the clients when the change of location has been approved. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detector and the carbon monoxide detector. Food Service. 2 days perishable and 7 days nonperishable food supply will be relocated the same day as the clients when the change of location has been approved. Appliances. New Stove burners, washer, and dryer inspected. Additional appliances will be relocated the same day as the clients when the change of location has been approved. Knives: will be locked/stored in the cabinet. Toxins: will be locked under the sink and in the garage. Medication will be stored in a locked cabinet. Medications will be relocated the same day as the clients when the change of location has been approved. First-Aid Kit & Activity Supplies: will be relocated the same day as the clients when the change of location has been approved.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
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: BEVERLY HOME
FACILITY NUMBER: 306006132
VISIT DATE: 03/24/2022
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Client & Staff Files. LPAs reviewed client and staff file storage area and examples of current client and staff files. Fire clearance was approved by Anaheim Fire and Rescue Inspector Alicia Badosa on 02/14/2022. Backyard. Backyard exit gate is operational and unlocked. Backyard has shaded area for outdoor activities and seating for clients. AD stated they will add additional shade and outdoor furniture for the clients. LPAs reviewed relocation plan with AD. AD stated that the clients will be relocated the same day as the furniture, medications, and food once the relocation has been approved. Staff will provide care and supervision during the entire moving process.

Component III was completed with AD during today’s inspection. During the inspection, LPAs explained the process of this application and about the post licensing inspection once the facility is licensed. AD was informed today that the facility is ready for licensure and final approval will be processed by the CAU supervisor in Sacramento. An exit interview was conducted and a copy of this report was discussed with and provided to AD.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC809 (FAS) - (06/04)
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