306006305-9-6-2023-22-AS-RMAZ-CV7QAE-20230830115950

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006305
Report Date: 08/30/2023
Date Signed: 09/06/2023 09:55:48 AM

Document Has Been Signed on 09/06/2023 09:55 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ACERA HEALTH, LLC		FACILITY NUMBER:	306006305
ADMINISTRATOR:	GOUGER, MAI		FACILITY TYPE:	772
ADDRESS:	1585 MIRAMAR DRIVE		TELEPHONE:	(949) 378-7982
CITY:	NEWPORT BEACH	STATE: CA	ZIP CODE:	92661
CAPACITY: 6		CENSUS: 0	DATE:	08/30/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Yolanda Wynne		TIME COMPLETED:	12:15 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) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation. An initial application to operate a Social Rehabilitation Facility was submitted to CCL on January 19, 2023 for (6) capacity ambulatory clients. Structure: The facility is a two story house with an attached garage with 3 client bedrooms, 3 full bathrooms, 1 office/med room, 1 multipurpose room, a kitchen, 1 dinning and 1 living room. The client’s bedrooms are spacious and will easily accommodate the client’s furnishings. There is an exit walkway on each side of the house. Air/Heating: Central air/heating system installed with a central panel to control entire house. Client Bedroom: Bedrooms will accommodate 6 clients with 3 shared room accommodating two clients. Bedrooms Staff: No bedroom designated for awake-staff. Bathrooms: All bathrooms have a working toilet, wash basin, walk in shower. Continued on LIC809-C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ACERA HEALTH, LLC	FACILITY NUMBER: 306006305
	VISIT DATE: 08/30/2023

NARRATIVE

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

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. There are fire extinguishers mounted on the wall through out the facility.

Appliances:
5 gas burner stove, 1 oven, a refrigerators, dishwasher, washer, and dryer are clean and noted to be operational.

Toxins:
All and any toxic chemicals, cleaning solutions and disinfectants inaccessible to clients are stored in a locked storage.

Water Temperature:
Tested and recorded maintained at a comfortable temperature and the water temperature measures 115.1 Fahrenheit degrees in bathrooms.

Medications, First-Aid Kit & Book:
In lock stage cabinet in office space

Continued on LIC809-C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ACERA HEALTH, LLC	FACILITY NUMBER: 306006305
	VISIT DATE: 08/30/2023

NARRATIVE

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Client & Staff Files:
Records will be kept locked cabinet space located in office.

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.

Fire clearance:
Was approved on July 27, 2023.

Component III:
Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities.

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

The applicant has met all pre-licensing requirements. LPA will submit notification to CAB in Sacramento for final review prior to license being issued.

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: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC809 (FAS) - (06/04)

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