306006295-3-23-2023-22-AS-RMAZ-CQ7NTF-20230323104441

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006295
Report Date: 03/23/2023
Date Signed: 03/23/2023 10:44:52 AM

Document Has Been Signed on 03/23/2023 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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	SENIOR FAMILY HOME 1		FACILITY NUMBER:	306006295
ADMINISTRATOR:	AGUSTIN, REYNALDO		FACILITY TYPE:	740
ADDRESS:	3148 W ROME AVENUE		TELEPHONE:	(714) 600-6195
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY: 6		CENSUS: 0	DATE:	03/23/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Reynaldo Agustin Administrator/Director Erlinda Pinkston		TIME COMPLETED:	11:00 AM

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) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation. 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 clients was submitted to CCL on 01/12/23. Structure: The facility is a one story house with an attached garage with 4 resident bedrooms, 3 bathrooms, 1 half bathroom, 1 TV room, a kitchen, and 1 dinning room. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with 1 exit walkway on the side of the house with a covered patio with seating for residents. Air/Heating: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms will accommodate 6 residents with 2 private rooms and 2 shared rooms accommodating two clients. Bedroom number 4 has a half bathroom. Bedroom number 4 is designated for bedridden resident per fire clearance. Continued on LIC809-D

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SENIOR FAMILY HOME 1	FACILITY NUMBER: 306006295
	VISIT DATE: 03/23/2023

NARRATIVE

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Bedrooms Staff:
No bedroom designated for awake-staff.

Bathrooms:
All bathrooms have a working toilet, wash basin, walk in shower.

Linens & Hygiene Supplies:
Adequate supply of linen stored in hallway cabinet space.

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 week prior and listed for food serve for one week.

Food Service:
Adequate supply of 7-day non-perishable and 2-day perishables are stored in the kitchen.

Smoke Detectors:
Smoke detectors and carbon monoxide alert systems are hardwired, were tested and found operational.

Appliances:
Gas 5 burner stove, single oven, 2 refrigerator (1 refrigerator in garage), microwave, 2 washers, and dryer are clean and noted to be operational.

Toxins:
All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are stored and locked in garage storage cabinet.

Continued on LIC809-C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SENIOR FAMILY HOME 1	FACILITY NUMBER: 306006295
	VISIT DATE: 03/23/2023

NARRATIVE

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Water Temperature:
Tested and recorded maintained at a comfortable temperature and the water temperature measures 106.8 Fahrenheit degrees in resident bathroom and common bathroom.

Medications, First-Aid Kit & Book:
Medication will be stored locked in kitchen cabinet, First aid kit will be stored in hallway storage and First Aid book will be stored with files in cabinet located in dinning room.

Resident & Staff Files:
Records and staff files will be kept in a locked cabinet located in dinning room.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation stored in cabinet located in living room.

Fire clearance:
Was approved on 02/16/23.

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

Applicant was reminded that it is required to notify LPA, within 5 business days of admitting the first resident. This notification may be done by phone, email or fax.

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.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC809 (FAS) - (06/04)

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