306006149-9-20-2022-22-AS-JHAY-CJFQBV-20220920120209

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006149
Report Date: 09/20/2022
Date Signed: 09/20/2022 12:02:16 PM

Document Has Been Signed on 09/20/2022 12:02 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:	CARE CONNECTION		FACILITY NUMBER:	306006149
ADMINISTRATOR:	GILBERT, ERIC		FACILITY TYPE:	740
ADDRESS:	416 S JENNIFER LANE		TELEPHONE:	(714) 289-2273
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	6	CENSUS: 4	DATE:	09/20/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Eric Gilbert		TIME COMPLETED:	12:10 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) Jerome Haley and Rosie Quiroz made an announced visit for the purpose of a pre-licensing evaluation. LPAs arrived at facility were greeted and granted entry by applicant Eric Gilbert. LPAs were taken around the back of the facility to enter through the visitors entrance. Upon entry, LPAs were signed in and LPA Haley observed a COVID screening station near the door. An initial application to operate an Adult Residential Facility for the Elderly, for (6) capacity, (1) ambulatory, (4) non-ambulatory, and (1) bedridden residents was submitted to CCL on 2/5/2022. Structure: The facility is a two-story structure, with an attached garage. There are six resident bedrooms, two staff bedrooms, one guest room, one living room, and one dining room. The resident bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with 2 exit ways on each side of the house with shaded seating area for residents. Second Floor: No residents will reside on second floor of house. There are two staff rooms and a vacant guest room. Signal system: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms are for 1 ambulatory and 4 non-ambulatory residents. Bedrooms # 1 will accommodate a bedridden resident. CONTINUED on LIC809-C

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

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: CARE CONNECTION	FACILITY NUMBER: 306006149
	VISIT DATE: 09/20/2022

NARRATIVE

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Bedrooms Staff:
2 bedrooms upstairs will be for live in staff.

Bathrooms:
All bathrooms have a working toilet, wash basin, walk in shower. Water Temperature in Bathroom #1 was measured at 113.1 degrees Fahrenheit and 105.6 degrees Fahrenheit in bathroom #2.

Linens & Hygiene Supplies:
Adequate supply of linen was stored in the hallway closet near the garage.

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:
An adequate supply of 7-day non-perishable and 2-day perishables were observed in the kitchen. There was an extra supply of non-perishable food items stored in a room in the garage. LPA Haley also observed an extra refrigerator in garage used to store insulin and hospice comfort kits.

Smoke Detectors:
Smoke detectors are hardwired and tested operational.

Appliances:
Gas 5 burner stove, single oven, 3 refrigerators (kitchen and garage), 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 attached garage.

CONTINUED on LIC809-C

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

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: CARE CONNECTION	FACILITY NUMBER: 306006149
	VISIT DATE: 09/20/2022

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Medications, First-Aid Kit & Book:
Medication are stored in a locked cabinet in the dining room and inaccessible to residents.
Resident & Staff Files:
Resident files and staff files are kept in the Administrative offices of the facility that is kept locked at all times and inaccessible to residents.
Bodies of water:
No bodies of water was observed. There's a dry Koi Pond in the backyard. The Applicant plans on making some repairs to the Koi Pond.
Fire Extinguisher:
Multiple fire extinguishers were observed. Full charged and mounted in the kitchen, living room, an upstairs hallway, and several extinguishers were observed in the garage.
Fire clearance:
Orange Fire Department granted the Fire Clearance June 16, 2022
Component III:
Will not be conducted at this time.

The following items need to be corrected prior to licensure:

Water leak on the side of the facility
Disposal items need to be removed from the side of the facility
Exit Alarms in bedrooms (1 & 2) need to be operational
Add bed to room #6
20x26 See Something Say Something poster place at the entrance of the facility.

The items mentioned above are to be corrected by October 4, 2022. LPAs will conduct a follow up visit to ensure corrections have been made.

An exit interview was conducted with Applicant Eric Gilbert, and a copy of this report was provided at exit.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

LIC809 (FAS) - (06/04)

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