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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006247
Report Date: 09/27/2023
Date Signed: 09/27/2023 11:55:25 AM


Document Has Been Signed on 09/27/2023 11:55 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:FAMILY CHOICE SENIOR LIVINGFACILITY NUMBER:
306006247
ADMINISTRATOR:JUNGE, PAMELAFACILITY TYPE:
740
ADDRESS:3105 W. ORANGE AVENUETELEPHONE:
(714) 229-0069
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:30CENSUS: 13DATE:
09/27/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Pamela JungeTIME COMPLETED:
12:10 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 met with designated Administrator (AD) Pamela Junge. An application to operate a Residential Care Facility for Elderly (RCFE) for (30) capacity, (0) ambulatory, (30) non-ambulatory, and (0) bedridden residents was received by CCL on 9/26/2022.

Structure:
The facility is a one-story building with 15 resident bedrooms, eight bathrooms, living room, kitchen, dining room, staff office, and attached two car garage used for storage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entranceway. There are two separate outdoor patio areas, each consisting of at least one shaded seating area. LPA did not observe any obstacles or hazards in outdoor areas.

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

Signal system
Facility has a functional signal system. Each resident has a signal control via wristwatch that sends notification to a staff pager that identifies which resident room the signal came from.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked in a kitchen cabinet and in the garage.

Medications, First-Aid Kit & Book:
Medication will be stored and locked in medication cart. First aid kits are stored throughout the facility and contain all the required elements.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023
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: FAMILY CHOICE SENIOR LIVING
FACILITY NUMBER: 306006247
VISIT DATE: 09/27/2023
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Resident & Staff Files:
Records will be kept locked in staff office.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
Fire extinguishers were observed to be mounted and fully charged.

Reading Material, Games, Equipment & Materials:
The facility has magazines, art and crafts supplies, games, and puzzles available for resident use in the living room.

Fire clearance:
Was approved by a fire inspector of Anaheim Fire Department on 04/26/2023. No special conditions noted.

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

Bedrooms Staff:


There is no staff bedroom.

Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured between 110.3-116.9 degrees Fahrenheit.

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

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available, means of exiting, emergency phone numbers and food menu.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023
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: FAMILY CHOICE SENIOR LIVING
FACILITY NUMBER: 306006247
VISIT DATE: 09/27/2023
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Food Service:
A supply of 2-day perishable and 7-day of non-perishable food will be maintained on hand.

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

Appliances:
Gas burner stove with oven, 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. Exit interview was conducted and a copy of this report was provided to designated AD.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3