306006205-11-3-2022-22-AS-RMAZ-CKTPWA-20221103114025

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006205
Report Date: 11/03/2022
Date Signed: 11/03/2022 11:40:36 AM

Document Has Been Signed on 11/03/2022 11:40 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:	LIFE CARE GUEST HOME LLC		FACILITY NUMBER:	306006205
ADMINISTRATOR:	AVILA, MARIA JASMIN		FACILITY TYPE:	740
ADDRESS:	22322 SAVONA		TELEPHONE:	(714) 609-2303
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY:	6	CENSUS: 0	DATE:	11/03/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Maria Jasmin Avila Liza DelaCruz		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. An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden resident was submitted to CCL on 07/08/22. Structure: The facility is a two story house with an attached garage with 5 resident bedrooms, 4 half bathrooms, 1 full bathroom, 1 TV room, a kitchen. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with 1 exit walkways on each side of the house with covered seating for the residents. Facility 2^nd floor will be used for staff break/lunch room. Air/Heating: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms are for 0 ambulatory, 5 non-ambulatory, and 1 bedridden resident. Bedrooms will accommodate 6 residents with 4 private rooms and 1 shared room accommodating two clients. Bedrooms 2, 3 and 5 have a half bathroom. Bedrooms Staff: No bedroom designated for awake-staff. Continued on LIC809-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022

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: LIFE CARE GUEST HOME LLC	FACILITY NUMBER: 306006205
	VISIT DATE: 11/03/2022

NARRATIVE

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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 cabinet 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 with surplus goods stored in kitchen as well.

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

Appliances:
Electric four-burner stove, single oven, 1 refrigerator, microwave, washer, and dryer are clean and noted to be operational.

Toxins:
All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are stored and locked in hallway storage.

Water Temperature:
Tested and recorded maintained at a comfortable temperature and the water temperature measures 116.7 Fahrenheit degrees in resident restrooms and common bathroom.

Continued on LIC809-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022

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: LIFE CARE GUEST HOME LLC	FACILITY NUMBER: 306006205
	VISIT DATE: 11/03/2022

NARRATIVE

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Medications, First-Aid Kit & Book:
Medication and First Aid kit stored in locked storage cabinet in kitchen.

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

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 08/04/22.

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

Applicant was reminded that it is required to notify LPA, within 5 business days of admitting the first resident. This notification may be done by phone, email or fax.

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.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022

LIC809 (FAS) - (06/04)

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