<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006178
Report Date: 10/12/2022
Date Signed: 10/12/2022 11:29:28 AM

Document Has Been Signed on 10/12/2022 11:29 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:POLLY'S PLACEFACILITY NUMBER:
306006178
ADMINISTRATOR:VALENCIA, POLLYFACILITY TYPE:
740
ADDRESS:2143 W. FIR AVE.TELEPHONE:
(949) 412-2579
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 0DATE:
10/12/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Polly ValenciaTIME COMPLETED:
11:43 AM
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) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Administrator (AD) Polly Valencia, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 04/07/2022. This is an initial application with no residents in care.

During the inspection, LPA and AD observed the following: Structure. This is a one-story home. Facility is a 6-bedroom, 7-bathroom, 1 story house with detached garage that is being used for storage. There is a back yard with a patio cover for the residents. Facility telephone number is (714) 603-7520. Resident Bedrooms. The 6 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Lamps, chairs, linens, and storage for each resident bedroom inspected. Staff Bedrooms. There are no staff bedrooms, but there is a staff break room. AD stated that overnight supervision will be provided by wake overnight staff. AD stated that if this provision is not already included in the plan of operation, AD will submit an addendum to AD’s CAB analyst to add to the plan of operation. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 110 to 114 F degrees. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. 7 days nonperishable food supply reviewed and AD stated they will obtain 2 days perishable food prior to accepting residents. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen cabinet. Toxins: observed locked in laundry room cabinet. Medication cabinet is locked. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files. This is an initial inspection and LPA observed storage space for resident and staff files. Fire clearance was approved by Anaheim Fire Department Inspector Alicia Badosa on 09/07/2022.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: POLLY'S PLACE
FACILITY NUMBER: 306006178
VISIT DATE: 10/12/2022
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
26
27
28
29
30
31
32
Backyard. Backyard exit gate is operational and unlocked. Backyard has shaded area for outdoor activities and sufficient seating for residents. Component III was completed with AD during today’s inspection. AD will obtain liability insurance once the application is approved.

During the inspection, LPA 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 CAB supervisor in Sacramento. An exit interview was conducted and a copy of this report was discussed with and provided to AD.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2