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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006221
Report Date: 03/08/2023
Date Signed: 03/09/2023 07:03:44 AM

Document Has Been Signed on 03/09/2023 07:03 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:MARY'S LOVING CARE BFACILITY NUMBER:
306006221
ADMINISTRATOR:HAN, XUFACILITY TYPE:
740
ADDRESS:341B 16TH PLACETELEPHONE:
(626) 232-4190
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 6CENSUS: 3DATE:
03/08/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Xu "Emma" HanTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Lydia Martinez conducted this announced visit for the purpose of conducting a Pre-Licensing inspection. LPA met with Applicant (AP) Xu "Emma" Han, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly (RCFE). Application was submitted to Community Care Licensing on 08/01/2022. Facility is an existing facility and undergoing a Change of Ownership. There are 3 Residents in care under the current license. Facility is a one story, 4 bedroom, 4 bathroom home with an attached garage. A Fire Clearance was granted for 6 non-Ambulatory Residents on 12/08/2022. Facility is secured by a fence around the property. Adequate seating is available in the dining room as well as the living room. One resident bedroom of the 4 bedrooms is double occupancy and all are equipped with appropriate lighting, chair, night stand and ample closet space. One bathroom of the 4 has a toilet, wash basin, and walk-in shower. Other 3 bathrooms have only toilet and wash basin. Linen supply is ample supply for residents. Facility has a current food supply of two day perishables and seven day non-perishables. Smoke and carbon monoxide detectors are centrally wired and are operational. Fire extinguishers are mounted and charged. Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins were locked/stored in the locked garage. Hot water in bathroom was tested and is within regulatory requirements. First Aid kit observed contained all required items. Medication and files are stored in the locked office. The facility has activity supplies such as board games and puzzles. Facility has a patio table, chairs and an umbrella for shade. Side exit gate is unlocked and self latching. The Component III was waived as Component III was done on 2/15/2023 during the Pre-Licensing of Mary's Loving Care A. Facility is currently operating under the liability insurance of current facility Irvine Cottages/Laney's Cottages Eastside B (306005955). AP will switch liability insurance to new facility once the application is approved.
The Pre-Licensing is complete and this facility has no deficiencies. All elements verified by LPA appear to be in compliance and the facility is ready to be licensed. The license will be granted upon completion of a final review and approval from the Application Specialist. An exit interview was conducted and a copy of this report will be sent to email on file.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023
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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