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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006291
Report Date: 04/18/2023
Date Signed: 04/18/2023 10:42:58 AM


Document Has Been Signed on 04/18/2023 10:42 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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:WE CARE SENIOR LIVINGFACILITY NUMBER:
306006291
ADMINISTRATOR:SANSANO, CHERYLFACILITY TYPE:
740
ADDRESS:24891 BRANCH AVETELEPHONE:
(949) 395-0586
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 5DATE:
04/18/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Cherryl SansanoTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an announced Pre-Licensing visit on today’s date. LPA arrived at facility was greeted and granted entry by Administrator Cherryl Sansano.

An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden resident was submitted to CCL on 01/03/23.



LPA Martinez observed the following:

Structure:
Facility is a two story house with 4 resident bedrooms, 2 bathrooms, living room, dining area, and kitchen. Upstairs there are 2 staff bedrooms with 1 bathroom. There is an attached 2 car garage that houses the washer and dryer. The backyard has a shaded concrete area with seating for residents. The exit gate on the exterior of the home have self-closing and self-latching mechanisms.
Signal System:
The facility's central heating and air conditioning is controlled by a thermostat located in a hallway. All exit doors were equipped with an auditory alarm and were noted to be in operating condition.
Bedrooms Residents:
All bedrooms accommodate non-ambulatory residents with bedroom #3 designated for a bedridden resident. The resident bedrooms accommodate residents' furnishings such as a bed, lamp, night stand, dresser drawers and a closet.

Continued on LIC809-C
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023
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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: WE CARE SENIOR LIVING
FACILITY NUMBER: 306006291
VISIT DATE: 04/18/2023
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Bathrooms:
All bathrooms have a working toilet and wash basin with 2 bathrooms containing a walk-in shower. Grab bars were present as a well as a non-skid mats.
Linens and Hygiene Supplies:
Adequate supply of linens is stored in bathroom storage cabinet. The hygiene supplies were stored in a locked cabinet in kitchen.
Emergency Phone Numbers, Exit Plan:
Readily available for review in the entry way with a facility sketch and exit plan.
Food Service and Menu:
There was an adequate supply of 7 day non-perishable and 2 day perishables present in the facility. The sample menu was available for review. Additional food supplies will be located in the garage.
Smoke and Carbon Monoxide Detectors:
Smoke and carbon monoxide alert systems are wireless, were tested and found operational.
Fire Extinguisher:
Fully charged and mounted on a wall in the kitchen and another one mounted on a wall just outside of the kitchen dated 5/10/22.
Fire Clearance:
Approved on 02/21/23 for 5 non-ambulatory residents with 1 bedridden resident.
Appliances:
Gas four burner stove with overhead fan and light, single oven, refrigerator/freezer, microwave, and dishwasher. The washer and dryer are located in the garage and noted to be in operating condition.
Toxins and Sharps:
Locked and stored in a locked cabinet located in the garage. The knives and other sharp items are stored in a locked kitchen cabinet underneath sink.
Water Temperature:
Tested and recorded maintained at a comfortable temperature and the water temperature measures 105.6 Fahrenheit degrees in facility bathrooms.
Medications, First-Aid Kit & Book:
Medication locked and stored in a cabinet underneath staircase. First aid kit on top of medication cabinet. First aid book stored with records in dining room.

Continued on LIC809-C
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: WE CARE SENIOR LIVING
FACILITY NUMBER: 306006291
VISIT DATE: 04/18/2023
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Resident & Staff Files:
Records will be kept locked in a cabinet in dining room.
Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the resident's use, commensurate with the plan of operation.
Component III:
Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities.

Facility appears to be ready for licensure. Accordingly, LPA will submit file for approval to CCL Supervisor. Exit interview was conducted and a copy of this report was left with the applicant.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3