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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006250
Report Date: 04/24/2023
Date Signed: 04/24/2023 04:03:23 PM


Document Has Been Signed on 04/24/2023 04:03 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:ST. CLAIR SENIOR CAREFACILITY NUMBER:
306006250
ADMINISTRATOR:GARCIA, MARY JOY CFACILITY TYPE:
740
ADDRESS:830 SAINT CLAIR ST.TELEPHONE:
(562) 521-4966
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 0DATE:
04/24/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Mary Joy GarciaTIME COMPLETED:
04:15 PM
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Licensing Program Analysts (LPAs) Dwayne Mason Jr. and Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPAs met with Applicant (AP) Mary Joy Garcia, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 10/31/2022. This is an initial application with no residents in care.

During the inspection, LPAs and AP observed the following: Structure. This is a one-story home. Facility is a 5-bedroom, 3-bathroom, 1 story house with attached garage that is being used for storage. There is a back yard with a patio cover for the residents. Facility telephone number is (657) 235-8725. Resident Bedrooms. The 4 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Lamps, chairs, linens, and storage for each resident bedroom inspected. Staff Bedrooms. The 1 staff bedroom is spacious and will easily accommodate the staff’s furnishings. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 119.4 and 119.6 F degrees. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. 7 days nonperishable food supply reviewed and AP stated they will obtain 2 days perishable food prior to accepting residents. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen drawer. Toxins: observed locked in the cleaning closet and under the kitchen sink. Medication cabinet is locked. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files. This is an initial inspection and LPAs observed storage space for resident and staff files. Fire clearance was approved by City of Costa Mesa Fire Prevention Inspector Ben Castillo on 02/07/2023. Backyard. Backyard exit gate is operational and unlocked. Backyard has shaded area for outdoor activities and sufficient seating for residents. Component III was completed with AP during today’s inspection. AP will obtain liability insurance once the application is approved.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
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: ST. CLAIR SENIOR CARE
FACILITY NUMBER: 306006250
VISIT DATE: 04/24/2023
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During the inspection, LPAs explained the process of this application and about the post licensing inspection once the facility is licensed. AP was informed today that the facility is ready for licensure and final approval will be processed by the CAB supervisor in Sacramento. An exit interview was conducted and a copy of this report was discussed with and provided to AP.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC809 (FAS) - (06/04)
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