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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006218
Report Date: 11/20/2023
Date Signed: 11/20/2023 01:51:37 PM

Document Has Been Signed on 11/20/2023 01:51 PM - 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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ADLER HEALTHFACILITY NUMBER:
306006218
ADMINISTRATOR:MCPHAIL, ANDREFACILITY TYPE:
772
ADDRESS:1068 SAN PABLOTELEPHONE:
(310) 909-3400
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 0DATE:
11/20/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Andre McPhail
Charles McPhail 		TIME COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an announced visit to the facility for the purpose of a pre-licensing evaluation.

An initial application to operate a Social Rehabilitation Facility was submitted to CCL on 07/26/22 for (6) capacity ambulatory clients.

Structure:
The facility is a one story house with a garage with 3 client bedrooms, 2 full bathrooms, a dinning, a living room and 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 one side of the house with covered seating for the clients.Air/Heating: Central air/heating system installed with a central panel to control entire house. Client Bedrooms: Bedrooms will accommodate 6 clients with 3 shared bedrooms accommodating two clients. Bedrooms Staff: No bedroom designated for awake-staff. 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. Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired, were tested and found operational. Appliances: 5 burner electric stove, 1 oven, a refrigerators, dishwasher, microwave, washer, and dryer are clean and noted to be operational. Toxins: All and any toxic chemicals, cleaning solutions and disinfectants
Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2023
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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ADLER HEALTH
FACILITY NUMBER: 306006218
VISIT DATE: 11/20/2023
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inaccessible to clients are stored in garage. Water Temperature: Tested and recorded maintained at a comfortable temperature and the water temperature measures 114.9 Fahrenheit degrees in bathrooms. Medications, First-Aid Kit & Book: In lock storage closet in office space. Client & Staff Files: Records will be kept locked cabinet space located in 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 02/02/2023. 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 client. This notification may be done by phone, email or fax.

The applicant has met all pre-licensing requirements. LPA will submit notification to CAB in Sacramento for final review prior to license being issued.

Exit interview was conducted and a copy of this report was left with the applicant.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
LIC809 (FAS) - (06/04)
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