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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006191
Report Date: 11/10/2022
Date Signed: 11/10/2022 11:29:55 AM

Document Has Been Signed on 11/10/2022 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:HAILEY PRISCILLA HOMEFACILITY NUMBER:
306006191
ADMINISTRATOR:KABILING, MARIA DOLOR G.FACILITY TYPE:
735
ADDRESS:2427 E. LINCOLN AVENUETELEPHONE:
(714) 956-5662
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 5DATE:
11/10/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maria Kabiling
Susan Kabiling		TIME COMPLETED:
11:50 AM
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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 Maria Kabiling and granted entry.

An initial application to operate an Adult Residential Facility (ARF), for (6) capacity, (6) ambulatory, (0) non-ambulatory, and (0) bedridden clients was submitted to CCL on 05/11/2022.

Structure:
The facility is a one story house with an attached garage with 3 resident bedrooms, 2 staff bedrooms, 4 full bathrooms, 1 TV room, a kitchen. The client’s bedrooms are spacious and will easily accommodate the client’s furnishings. There is a large back yard with 1 exit walkways on one side of the house, an exit is located directly from backyard to alley. 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 6 ambulatory, 0 non-ambulatory, and 0 bedridden client. Bedrooms will accommodate 6 clients with 3 shared bedrooms accommodating two clients per. Bedroom 1 has a bathroom.

Bedrooms Staff:
There is 2 bedrooms for live in staff.

Continued on LIC809-D
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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 3
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: HAILEY PRISCILLA HOME
FACILITY NUMBER: 306006191
VISIT DATE: 11/10/2022
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Bathrooms:
All bathrooms have a working toilet, wash basin, walk in 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. Surplus goods stored in storage cabinet in hallway of staff bedrooms.

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

Appliances:
Gas four-burner stove, single oven, 2 refrigerator (one in located in garage), 1 freezer (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 105.4 – 114.9 Fahrenheit degrees in clients restrooms and common bathroom.

Continued on LIC809-D
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: HAILEY PRISCILLA HOME
FACILITY NUMBER: 306006191
VISIT DATE: 11/10/2022
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Medications, First-Aid Kit & Book:
Medication and First Aid kit stored in locked storage cabinet in office.

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

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 07/6/2022.

Component III:
Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities.

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 with the applicant.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC809 (FAS) - (06/04)
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