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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006240
Report Date: 03/15/2023
Date Signed: 03/15/2023 10:44:05 AM

Document Has Been Signed on 03/15/2023 10:44 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:HOUSE OF HOPE OF BUENA PARKFACILITY NUMBER:
306006240
ADMINISTRATOR:CINTRON, VIVIANA REYNAGAFACILITY TYPE:
740
ADDRESS:8441 SAN MARINO DRTELEPHONE:
(562) 325-0572
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 0DATE:
03/15/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Viviana Cintron
Eric Magana		TIME COMPLETED:
11:00 AM
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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 was greeted and granted entry by designated Administrator (AD) Viviana Cintron. Eric Magana was also present and will serve as Administrator at the facility as well. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (1) ambulatory, (4) non-ambulatory, and (1) bedridden residents was received by CCL on 9/08/2022.

Structure:
The facility is a one-story home with four resident bedrooms, two bathrooms, living room, kitchen, and an attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the living room area. There is a back yard with one exit gate on one side of the house. There is a shaded seating area in the backyard. No bodies of water were observed. LPA did not observe any obstacles or hazards in the backyard.

Resident Bedrooms
All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened.

Signal system
There is no signal system.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked beneath the kitchen sink.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2023
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HOUSE OF HOPE OF BUENA PARK
FACILITY NUMBER: 306006240
VISIT DATE: 03/15/2023
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Medications, First-Aid Kit & Book:
Medication will be stored in a locked cabinet. First aid kits are stored in the entranceway sign-in area of the facility and in the kitchen. The first aid kits have all the required elements.

Resident & Staff Files:
Records will be kept locked in storage cabinet located in the living room.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
All fire extinguishers are fully charged.

Reading Material, Games, Equipment & Materials:
The facility has board games, puzzles, and card games for resident use. Facility staff will also encourage arts and crafts and group activities.

Fire clearance:
Was approved by a fire inspector of Orange County Fire Authority on 12/21/2022. Special conditions noted
“RM 1 = (1) bedridden, (1) non-ambulatory
RM 2 = (1) non-ambulatory
RM 3 = (2) non-ambulatory
RM 4 = (1) ambulatory”

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

Bedrooms Staff:


Staff will not be living on site.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HOUSE OF HOPE OF BUENA PARK
FACILITY NUMBER: 306006240
VISIT DATE: 03/15/2023
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Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured between 109.9 - 111.9 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in each resident bedroom closet.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was posted and visible.

Food Service:
There is a supply of 2-day perishable and 7-day of non-perishable food on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas four burner stove with 1 flat stove top grill, 1 oven, 1 refrigerator, dish washer, microwave, washer, and dryer are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An 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: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
LIC809 (FAS) - (06/04)
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