306006244-11-17-2022-22-AS-JALE-CL9TSH-20221117135911

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006244
Report Date: 11/17/2022
Date Signed: 11/17/2022 02:00:46 PM

Document Has Been Signed on 11/17/2022 02:00 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:	AMORE SENIOR LIVING		FACILITY NUMBER:	306006244
ADMINISTRATOR:	KHAY, RUTH		FACILITY TYPE:	740
ADDRESS:	25011 MONTE VERDE DRIVE		TELEPHONE:	(949) 503-1939
CITY:	LAGUNA NIGUEL	STATE: CA	ZIP CODE:	92677
CAPACITY:	6	CENSUS: 6	DATE:	11/17/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Ruth Khay, Chet Khay		TIME COMPLETED:	02:16 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) Joseph Alejandre made an announced visit to conduct the pre-licensing inspection. LPA was screened for symptoms of Covid-19 and granted entry. LPA met with applicants Chet Khay and Ruth Khay. LPA explained the reason for the visit. An application to operate a Residential Care Facility for the Elderly (RCFE) for a capacity of 6 non-ambulatory residents and 0 bedridden residents for a total capacity of 6 residents and hospice waiver for 6 was submitted to Community Care Licensing (CCL), the application is dated 9/10/2022. Facility phone number 949-503-1939. LPAs and applicants toured the facility. LPA observed the following. Structure: The facility is a single story home with 7 bedrooms, 6 bathrooms, dining room, kitchen, living room and a 2 car garage. that is used storage. LPA observed the fireplace in the living room is boarded up and inaccessible to residents. Resident rooms Resident rooms are private rooms which have a closet. All resident rooms have the required furnishings, bed, night stand, lamp and a chair. All rooms were clean and organized. Signal system Facility is has a fire clearance for, 6 non-ambulatory residents in single family home consisting of one floor and one building, a signal system is not required. Bathrooms: All 6 bathrooms have working plumbing. LPA observed all bathrooms are clean and operational. LPA measured the hot water in each bathroom. Hot water measured 113.5 degrees Fahrenheit to 117.1 degrees Fahrenheit.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022

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: AMORE SENIOR LIVING	FACILITY NUMBER: 306006244
	VISIT DATE: 11/17/2022

NARRATIVE

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Pool/Jacuzzi & Pets:
No pools or hot tubs at the facility. No bodies of water observed at the facility. The backyard has a table with chairs and an umbrella. The exit gate is latched and operational. No obstacles or hazards observed in the backyard.

Linens & Hygiene Supplies:
Adequate supply of linen and cleaning supplies stored in the supply closets.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one month prior and listed for food served for one month. Emergency food and water supply is stored in a storage room.

Food Service:
LPA observed the kitchen is clean and organized. The freezer and refrigerator are at the required temperatures. LPA observed a 2 day perishable food supply and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the stove lights unassisted.

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

Toxins:
All toxic chemicals, cleaning solutions, laundry toxins and disinfectants used by the facility are stored locked under the kitchen sink and inaccessible to residents.

Medications, First-Aid Kit & Book:
Medication is stored in a locked cabinet in the kitchen. There is a first aid kit stored in the hallway. The first aid kit has all the required elements.

Resident & Staff Files:
All resident and staff files are kept in a cabinet in the dining room. This is a change of ownership pre-licensing visit, no files reviewed.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022

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: AMORE SENIOR LIVING	FACILITY NUMBER: 306006244
	VISIT DATE: 11/17/2022

NARRATIVE

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Fire Extinguisher:
The fire extinguisher in the kitchen is fully charged and was inspected on 11/8/2022.

Reading Material, Games, Equipment & Materials:
The facility has, books, magazines and a TV in the living room. Each resident room has a TV.

Fire clearance:
Fire clearance was approved by Orange County Fire Authority inspector Andrew Amante on 10/6/2022. Fire clearance is approved for 6 non-ambulatory residents. Delayed egress exits are not approved.

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

Applicants were notified that the final application approval will be issued by the Centralized Applications Bureau (CAB) in Sacramento. LPA informed the applicants that once the facility is licensed a post licensing visit will be conducted within 90 days of licensure. LPA did not observe any obstacles or hazards inside or outside of the facility. No deficiencies observed during the visit. The facility meets Title 22 requirements and is ready to be licensed. Exit interview was conducted and a copy of this report was provided to the applicants.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022

LIC809 (FAS) - (06/04)

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