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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006226
Report Date: 04/13/2023
Date Signed: 04/13/2023 02:33:15 PM

Document Has Been Signed on 04/13/2023 02:33 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:UMMA ADULT DAY HEALTH CENTERFACILITY NUMBER:
306006226
ADMINISTRATOR:CHAUDRY, SHAHIDFACILITY TYPE:
775
ADDRESS:14471 CHAMBERS RD #105TELEPHONE:
(949) 322-7811
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 30CENSUS: 0DATE:
04/13/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Shahid ChaudryTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility and met with designated Administrator (AD) Shahid Chaudry. An application to operate an Adult Day Program (ADP) for (30) capacity, (30) ambulatory, (0) non-ambulatory, and (0) bedridden clients was received by CCL on 7/18/2022.

Structure:
The facility is a one-story suite within a two-story business complex. The suite consists of a lobby, a staff office, a storage room, dining/activity area, kitchen, and one bathroom. There is no yard. There is a shaded seating area in the courtyard of the complex. LPA did not observe any obstacles or hazards in facility walkways.

Client Bedrooms
No clients will be living on site.

Signal system
There is no signal system.

Toxins:
All and any toxic chemicals, cleaning solutions, and disinfectants are inaccessible to clients and will be stored and locked in the storage room.

Medications, First-Aid Kit & Book:
Medication will be stored in a locked cabinet. First aid kit is mounted on the wall in the staff office. The first aid kit has all the required elements.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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: UMMA ADULT DAY HEALTH CENTER
FACILITY NUMBER: 306006226
VISIT DATE: 04/13/2023
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Resident & Staff Files:
Records will be kept locked in storage cabinet located in staff office.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
All fire extinguishers are mounted and fully charged.

Reading Material, Games, Equipment & Materials:
The facility has an air hockey table for client use. Card games, arts and crafts, toys and sensory items will also be provided.

Fire clearance:
Was approved by a fire inspector of Orange County Fire Authority on 11/09/2022. Special conditions noted “Suite 105 approved for adult day-care.”

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Bedrooms Staff:


No staff will be living on site.

Bathrooms:
Bathroom has working plumbing and designated hand washing posters. Hot water measured at 108.5 degrees Fahrenheit.

Emergency Phone Numbers & Exit Plan:
Posted and available for review an emergency disaster plan with means of exiting and emergency phone numbers listed.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
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: UMMA ADULT DAY HEALTH CENTER
FACILITY NUMBER: 306006226
VISIT DATE: 04/13/2023
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Smoke Detectors:
Smoke detector and carbon monoxide detector tested operational.

Appliances:
Electric four burner stove with one oven, one refrigerator, dish washer, and microwave are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
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