306006236-7-27-2023-22-AS-DLMN-CU5VPG-20230727163644

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006236
Report Date: 07/26/2023
Date Signed: 07/27/2023 04:37:20 PM

Document Has Been Signed on 07/27/2023 04:37 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	FULLERTON SWEET HOME		FACILITY NUMBER:	306006236
ADMINISTRATOR:	MOON, DONGHYUN		FACILITY TYPE:	740
ADDRESS:	516 S JENSEN WAY		TELEPHONE:	(714) 345-5478
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92833
CAPACITY: 6		CENSUS: 0	DATE:	07/26/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Donghyun Moon, Administrator		TIME COMPLETED:	04:00 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) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility at 1:05pm and was greeted and granted entry by designated Administrator (AD) Donghyun Moon. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden clients was received by Community Care Licensing (CCL) on 9/2/2022. Structure: The facility is a one-story home with five resident bedrooms, three full bathrooms, two half bathrooms, living room, kitchen, dining room, garage, staff bedroom and backyard. The backyard is not equipped for outdoor use, because there are no outdoor seating areas. LPA observed a posted See Something, Say Something poster. However, this was not the 20” x 26” PUB 475. There are two outdoor exit gates on either side of the facility. The Northeast exit gate is accessible from all exits except for the Bedroom 3 exit. The Southwest exit gate is only accessible through the Bedroom 3 exit. Doors inside the house are delayed egress and approved via fire clearance. Client Bedrooms: All resident bedrooms had the required furnishings except for Bedroom 3. LPA observed all other resident beds had linens and blankets. Bedroom 3 does not have a bed. LPA observed all windows were screened. The screen in Bedroom 2 has a hole in it. Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked in the garage. Medications, First-Aid Kit & Book: Medication will be stored in a locked drawer in the Dining room. First aid kit is stored in a cabinet in the Dining Room. The first aid kit has all the required elements.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: FULLERTON SWEET HOME	FACILITY NUMBER: 306006236
	VISIT DATE: 07/26/2023

NARRATIVE

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Resident & Staff Files: Records will be kept in a cabinet in the garage.

Fire Extinguisher: LPA observed two fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone. LPA observed a service tag for both fire extinguishers which indicates the fire extinguishers were last serviced on 9/29/22.

Reading Material, Games, Equipment & Materials: The facility has activity materials that will be kept in the garage. Puzzles and coloring books will be kept for resident use.

Fire clearance: Was approved by a fire inspector of the Fullerton Fire Department on 6/1/2023.

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

Bathrooms: All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 111.3 degrees Fahrenheit in the bathroom attached to the Dining Room. Hot water measured at 105.6 degrees Fahrenheit in Bedroom 4’s bathroom. Hot water measured at 114.4 in the bathroom outside of Bedroom 2. Hot water measured at 109 Degrees Fahrenheit in the bathroom next to Bedroom 1. The closet in Bedroom 3 is a small bathroom with a toilet and cabinets and no sink or shower.

Linens & Hygiene Supplies: A supply of extra linen was stored in cabinets in the hallway.

Emergency Phone Numbers, Exit Plan & Menu: An emergency disaster plan with means of exiting, emergency phone numbers and Menus are all posted.

Food Service: There is no supply of 2-day perishable or 7-day of non-perishable food on hand.

Smoke Detectors: Smoke detectors were observed to be dual Smoke & Carbon Monoxide detectors that are stationed throughout the home. The dual detectors were tested and observed to be operational.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: FULLERTON SWEET HOME	FACILITY NUMBER: 306006236
	VISIT DATE: 07/26/2023

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Appliances: Gas five burner stove with 1 oven, 1 refrigerator, dish washer, microwave, washer, and dryer are operational. 2 additional refrigerators are being stored on-site. One is in the garage and the other is in the laundry room. These 2 additional refrigerators were observed to be unsanitary and in disrepair.

The following corrections are needed before applicant is ready for licensure:

1. Bedroom 3 needs to be equipped with all necessary furnishings

2. The screen in Bedroom 2 needs to be repaired or replaced
3. The facility needs to be stocked with a 7-day non-perishable food supply
4. Replace See Something, Say Something sign with the 20" x 26" PUB475
5. The two unsanitary refrigerators need to be removed from the facility
6. Provide a shaded outdoor seating area for resident's to use for activities
7. LPA Mason will contact CAB regarding the unlabeled bathroom in Bedroom 3 and will notify the applicant of any necessary actions to be completed.

The due date for this correction is Tuesday, August 25, 2023 by close of business (COB)

Exit interview was conducted and a copy of this report was provided to designated AD.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC809 (FAS) - (06/04)

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