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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006316
Report Date: 03/19/2024
Date Signed: 03/19/2024 01:03:59 PM

Document Has Been Signed on 03/19/2024 01:03 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:ROSE HOUSEFACILITY NUMBER:
306006316
ADMINISTRATOR:OLUSOJI, ADEDOLAPOFACILITY TYPE:
735
ADDRESS:6639 SAN ALANO CIRCLETELEPHONE:
(714) 392-4135
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 4CENSUS: 0DATE:
03/19/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Omodupe Taiwo - Applicant TIME COMPLETED:
01:10 PM
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Licensing Program Analysts (LPAs) Jerome Haley, Edward Kim and Licensing Program Manager (LPM) Lourdes Montoya made an announced visit for the purpose of conducting a pre-licensing evaluation. LPAs Haley, Kim and LPM Montoya were greeted and granted entry by applicant Omodupe Taiwo . Upon entry, LPA Haley observed a COVID screening station near the entrance of the facility equipped with hand sanitizer, surgical mask, and gowns.

An initial application to operate an Adult Residential Facility, with a capacity of 4 ambulatory clients was submitted to CCL on February 8, 2024. Fire clearance: Orange County Fire Authority granted the Fire Clearance January 22, 2024


Structure:
The facility is a single level structure, with an attached garage. There are four client bedrooms, one living room, and one dining room. Bedrooms Residents: All bedrooms are for ambulatory clients and have the required furnishings: bed, lamp, chair, and storage space. Bathrooms: Bathroom one is equipped with a working toilet, wash basin, and walk in shower. Hot Water Temperature in Bathroom #1 was measured at 97.7 degrees Fahrenheit and 113.9 degrees Fahrenheit in bathroom #2. Kitchen: The gas stove was operational, and all 5 burners were in good working order. Knives and sharp objects will be locked under the sink. Food Service: A nonperishable food supply was observed in the cabinet next to the stove. An emergency food supply was observed under the sink. Garage: There are miscellaneous items that will be disposed of and exposed wires that need to be covered before being licensed. There is an extra refrigerator that will be used to store an additional food supply.

Resident & Staff Files: Resident files and staff files are kept in locked filing cabinet in the staff office area in between the dining room and laundry room
Continued on LIC809C
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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 2
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: ROSE HOUSE
FACILITY NUMBER: 306006316
VISIT DATE: 03/19/2024
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Medications, First-Aid Kit: Medication and first aid kit are stored in the staff office area.

Linens & Hygiene Supplies: Adequate supply of linen was stored in a cabinet in the laundry room. Extra hygiene supplies will be stored in the laundry room as well. All laundry detergents and hazardous cleaning items will be locked in the laundry room under the sink. Toxins: All toxic chemicals, cleaning solutions, laundry detergents and disinfectants are inaccessible to clients are stored in a locked cabinet below the sink in the laundry room.
Backyard/Exterior:
There is a large back yard with 2 exit ways on each side the house. A shaded patio area with a table and chairs was observed. All walkways were clear and free of obstruction. Bodies of water: No bodies of water were observed.

Air/Heating:
Central air/heating system installed with a central panel to control entire house. Smoke & Carbon Monoxide Detectors: Smoke and carbon monoxide detectors are hardwired and tested operational.

Emergency Phone Numbers, House Rules, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan, a list of emergency phone numbers, house rules, and a menu posted on the refrigerator in the kitchen.Fire Extinguisher: Observed full charged and mounted in the living room needs to be serviced and mounted correctly.

During the visit, the following was observed which must be corrected. 1. PUB475 See Something Say Something must be 20x26. 2. Bedroom 2 – Reposition bed and fix closet door hinge. 3. Service fire extinguisher and have it mounted on the correct way. 4. Have all cameras removed. 5. Have all items removed from behind the bushes in the backyard. 6. Cover exposed wires in the garage and add insulation and dry wall where needed. 7. Remove all clutter and excess items from the garage. 8. Place nonslip matts in the shower. 9. Have an internet accessible device for the clients. 10. Additional activities and/or games available for the clients. 11. Posted Evacuation plan. 12. Hot water in bathroom #1 needs to meet regulation requirements. The hot water temperature was 97.7 degrees Fahrenheit when tested a second time.
Component III: Will be waived as the facility is not ready to be licensed at this time.

An exit interview was conducted, and a copy of this report was provided to applicant Omodupe Taiwo.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC809 (FAS) - (06/04)
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