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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006230
Report Date: 10/26/2022
Date Signed: 10/26/2022 01:28:55 PM

Document Has Been Signed on 10/26/2022 01:28 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:TNL RESIDENTIAL CAREFACILITY NUMBER:
306006230
ADMINISTRATOR:LUU, THIENFACILITY TYPE:
735
ADDRESS:1665 S. IVANHOE ST.TELEPHONE:
(714) 797-6057
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 4CENSUS: 0DATE:
10/26/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Thien LuuTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an announced visit to conduct a pre-licensing inspection. LPA identified himself and explained the purpose of the visit with Applicant Thien Luu. An initial application to operate an Adult Residential Facility (ARF) was received by CCL on 08/31/2022 for a capacity of four ambulatory clients. Facility is to be vendorized by the Regional Center of Orange County, serving level 4C clients. Facility has no clients at this time.

LPA and Applicant toured the facility. LPA observed the following:
Structure: Facility is a single family one story home with; living room, eat in kitchen, 4 bedrooms, 2 bathrooms and a two car garage. Facility phone number is 714-797-6057. Common Areas: Adequate seating is available in the living room and kitchen. Bedrooms: rooms are single occupancy. All rooms have a bed, chair, night stand, lamp and closet. Bathrooms: Bathroom 1 is in bedroom 1. All bathrooms are clean and operational, grab bars are secure. Both showers have a non-skid mat. Linens & Hygiene Supplies: Facility has ample bedding, towels and hygiene supplies for clients. Emergency Phone Numbers and Exit Plan: Posted in entrance of facility along with Covid-19 postings. Food Service: Facility has 2 day perishable and 7 day non-perishable food supply on hand. Smoke Detectors: Smoke detectors/ carbon monoxide detectors tested operational during today's visit. Appliances: Refrigerator and stove are clean and operational. Toxins/ Sharps: Cleaning supplies and sharp objects are locked under the kitchen sink. Water Temperature: Hot water measured 112.6 degrees Fahrenheit in bathroom one and 113.4 degrees Fahrenheit in bathroom two. Emergency Supplies: LPA observed emergency food and water stored in the garage. LPA observed a 30 day PPE supply. Medications, First-Aid Kit & Book: Facility has a first aid kit which contained the required items. Medication will be stored and locked in a kitchen cabinet. Resident & Staff File: Files will be stored in medication cabinet. Reading Material, Games, and Equipment: LPA observed games and reading material and a TV in the living room. Outside areas: LPA observed a shaded outdoor patio area with a table and chairs. No bodies of water observed. The shed in the backyard is kept locked and used for storage.
Continued on LIC 809C.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2022
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: TNL RESIDENTIAL CARE
FACILITY NUMBER: 306006230
VISIT DATE: 10/26/2022
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Fire Clearance: Was approved for, four ambulatory clients on 9/13/22 by Anaheim Fire Department inspector Alicia Badosa.
No obstacles or hazards observed at the facility.

During the visit, LPA observed the following that must be correct prior to licensing.
  • Small holes in all of the bedroom walls, repair the holes and repaint the repaired areas.
  • All 4 client beds were missing, top flat sheets and mattress pads. put top flat sheets and mattress pads on all client beds.
  • Complete the infection control plan detailing how each mitigation regulation will be met.

Component three waived during visit. Applicant is Licensee/Administrator of additional facilities. LPA explained that the items listed above must be completed prior to the facility being licensed. During the visit LPA explained the process of this application and also about the post licensing visit once the facility is licensed. Applicant was informed today that the final approval will be processed by the CAB unit in Sacramento.

An exit interview was conducted and a copy of this report, LIC809 was explained and provided to the applicant.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC809 (FAS) - (06/04)
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