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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006318
Report Date: 03/22/2023
Date Signed: 03/22/2023 11:08:29 AM

Document Has Been Signed on 03/22/2023 11:08 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:AFESTIN HOMES IFACILITY NUMBER:
306006318
ADMINISTRATOR:FESTIN, ALEXANDERFACILITY TYPE:
735
ADDRESS:953 S SALEM STTELEPHONE:
(714) 325-0824
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 4CENSUS: 0DATE:
03/22/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Alexander Festin
Aliza Festin		TIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility and was greeted and granted entry by Assistant Administrator (AAD) Aliza Festin, designated Administrator (AD) Alexander Festin was also present. An application to operate an Adult Residential Facility (ARF) for (4) capacity, (4) ambulatory, (0) non-ambulatory, and (0) bedridden clients was received by CCL on 2/10/2023.

Structure:
The facility is a single-story home with four resident bedrooms, two bathrooms, living room, kitchen, and an unattached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the living room area. There is a back yard with two exit gates on each side of the house. There is a shaded seating area in the backyard. LPA did not observe any obstacles or hazards in the backyard.

Client Bedrooms
All client bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened.

Signal system
There is no signal system.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: AFESTIN HOMES I
FACILITY NUMBER: 306006318
VISIT DATE: 03/22/2023
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Medications, First-Aid Kit & Book:
Medication will be stored in a locked cabinet. First aid kit is stored with the medication. The first aid kit has all the required elements.

Resident & Staff Files:
Records will be kept locked in storage cabinet located in the living room area.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
All fire extinguishers are fully charged.

Reading Material, Games, Equipment & Materials:
The facility has board games that will be kept in the living room area, along with puzzles, coloring books and other sensory toys.

Fire clearance:
Was approved by a fire inspector of Anaheim Fire Department on 02/28/2023. No special conditions noted.

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

Bedrooms Staff:


Staff will not be living on site.

Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 109.2 degrees Fahrenheit.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: AFESTIN HOMES I
FACILITY NUMBER: 306006318
VISIT DATE: 03/22/2023
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Linens & Hygiene Supplies:
A supply of extra linen was stored in each client bedroom closet.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was posted and visible.

Food Service:
There is a supply of 2-day perishable and 7-day of non-perishable food on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas five burner stove with 1 oven, 1 refrigerator, dish washer, microwave, washer, and dryer are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC809 (FAS) - (06/04)
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