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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006171
Report Date: 02/08/2023
Date Signed: 02/08/2023 10:42:26 AM

Document Has Been Signed on 02/08/2023 10:42 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:ABLELIGHT, INC. -- PAPAGAYOFACILITY NUMBER:
306006171
ADMINISTRATOR:KUM, JENNIFERFACILITY TYPE:
735
ADDRESS:26372 PAPAGAYO DRTELEPHONE:
(707) 685-7067
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 4CENSUS: 0DATE:
02/08/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tony Duarte and Jennifer HrabelTIME COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Area Manager Tony Duarte. An initial application to operate an Adult Residential Facility was received by CCL on 03/18/2022 for a capacity of four ambulatory clients. Administrator Jennifer Hrabal arrived during the visit. Facility was previously licensed by Public Health as an Intermediate Care Facility. Licensee has surrendered the license.
LPA along with Administrator and Area Manager toured the facility at 9:11 AM and observed the following:
Structure: Facility is a two story, 5 bedroom, 3 bathroom house with an attached garage and a beige exterior. First floor has 2 bedrooms and two restrooms. Second story houses 2 bedrooms, one restroom and an office with an outside entrance. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Clients: Rooms will be single occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: All client bathrooms have a working toilet/ wash basin as well as non-skid surface in the shower. Facility has sanitizer and paper towels in the restrooms. Linens & Hygiene Supplies: Facility has bedding, towels and hygiene supplies for clients in care. Emergency Phone Numbers and Exit Plan: Emergency plan/ phone numbers located in facility office. Food Service: Facility does not have 2 day perishables and 7 day non-perishables as there are no clients present. LPA observed ample emergency food and water. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguishers are mounted and charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: Facility has secured area for toxins/ sharps in garage. Water Temperature: Tested and recorded between 107.4 and 111.9 degrees F in all restrooms. Medications, First-Aid Kit & Book: First aid kit observed contained all required items. Kit contained a first aid manual. Facility to use a medication administration record. Client & Staff File: Records to be secured in the facility office. Reading Material, Games, and Equipment: Facility has an activity schedule including exercise, arts and crafts and bible study. LPA observed games and art in the facility. CONTINUED ON LIC 809C DATED 02/08/2023.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2023
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ABLELIGHT, INC. -- PAPAGAYO
FACILITY NUMBER: 306006171
VISIT DATE: 02/08/2023
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Backyard: LPA observed a clean backyard with ample shaded seating for clients. Facility has a patio/ staircase on the second floor. Exit gates are self latching and unlocked. Fire Clearance: Approved for four ambulatory clients on 09/08/2022.

Licensee to address the following corrections and notify LPA by 02/22/2023:
  • Burner on the cook top is inoperable. Please repair/ replace.
  • Facility does not have an activity schedule or menu posted. Please post.
  • Facility does not have hand washing signs in the restrooms. Please post signage.
  • Facility does not have covid precaution signage at entrance of facility. Please post.
  • Facility does not have a sanitizing/ screening station at entrance of facility. Please utilize a screening station.


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




Exit interview conducted and a copy of this report will be left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC809 (FAS) - (06/04)
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