306006170-2-22-2023-22-AS-RMAZ-CPAR79-20230222114557

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006170
Report Date: 02/22/2023
Date Signed: 02/22/2023 11:46:15 AM

Document Has Been Signed on 02/22/2023 11:46 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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ABLELIGHT INC. --HARTOG		FACILITY NUMBER:	306006170
ADMINISTRATOR:	BONNIN, JILL		FACILITY TYPE:	735
ADDRESS:	25161 HARTOG ST		TELEPHONE:	(949) 472-9771
CITY:	LANGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY: 4		CENSUS: 3	DATE:	02/22/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jill Bonnin, Administrator Tony Duarte, Area Director		TIME COMPLETED:	12:00 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 Analyst (LPA) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at facility was greeted at the door by Jill Bonnin, Administrator and Tony Duarte, Area Director and was granted entry. An initial application to operate an Adult Residential Facility (ARF), for (4) capacity, (0) ambulatory, (4) non-ambulatory, and (0) bedridden clients was submitted to CCL on 03/18/2022. Structure: The facility is a one story house with an attached garage with 4 client bedrooms, 2 full bathrooms, 1 Living room, a kitchen. The client’s bedrooms are spacious and will easily accommodate the client’s furnishings. There is a large back yard with an exit walkway on each side of the house. There is covered seating for the clients in the backyard. Air/Heating: Central air/heating system installed with a central panel to control entire house. Bedrooms Clients: Bedrooms are for 4 non-ambulatory clients. Bedrooms will accommodate 4 clients with all bedrooms being private. Bedrooms 1 has a full bathroom. Bedrooms Staff: No live in staff. Continued on LIC809-D

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

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: ABLELIGHT INC. --HARTOG	FACILITY NUMBER: 306006170
	VISIT DATE: 02/22/2023

NARRATIVE

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Bathrooms:
All bathrooms have a working toilet, wash basin, and a shower.

Linens & Hygiene Supplies:
Adequate supply of linen stored in hallway storage space.

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. Additional food storage in garage refrigerator.

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

Appliances:
Gas four-burner stove, single oven, 2 refrigerators (one in located in garage), microwave, washer, and dryer are clean and noted to be operational.

Toxins:
All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to clients are stored and locked in the garage storage.

Water Temperature:
Tested and recorded maintained at a comfortable temperature and the water temperature measures 119.4 Fahrenheit degrees in bathrooms.

Continued on LIC809-D

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

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: ABLELIGHT INC. --HARTOG	FACILITY NUMBER: 306006170
	VISIT DATE: 02/22/2023

NARRATIVE

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Medications, First-Aid Kit & Book:
Medication and First Aid kit stored in locked storage cabinet in front room/med room.

Resident & Staff Files:
Records will be kept locked office space.

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 06/10/2022.

Component III:
Component III waived during the visit as Licensee is currently operating another facility.

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 at facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC809 (FAS) - (06/04)

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