306006320-9-27-2023-22-AS-RMAZ-CW3NXT-20230927105140

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006320
Report Date: 09/27/2023
Date Signed: 09/27/2023 10:51:49 AM

Document Has Been Signed on 09/27/2023 10:51 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:	MIRADA MANOR/GREENLEAF		FACILITY NUMBER:	306006320
ADMINISTRATOR:	BROWN, PRECIOUS		FACILITY TYPE:	735
ADDRESS:	8616 GREENLEAF STREET		TELEPHONE:	(818) 274-1809
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 6		CENSUS: 6	DATE:	09/27/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Joseph Jose		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. LPA arrived at facility was greeted and granted entry and met with Joseph Jose, Director/applicant. An initial application to operate an Adult Residential Facility (ARF), for (6) capacity, (6) ambulatory, (0) non-ambulatory, and (0) bedridden clients was submitted to CCL on 02/13/2023. Structure: The facility is a one-story house with an attached garage with 6 client bedrooms, 2 full bathrooms, 1 dining/living rooms, a family room, and a kitchen. The clients’ bedrooms are spacious and will easily accommodate the clients’ furnishings. There is a large back yard with one exit walkway on one side of the house with seating for the clients. Air/Heating: Air system installed individually in each of the clients’ bedrooms and common spaces. Bedrooms Clients: Bedrooms will accommodate 6 clients with all bedrooms being private. Bedrooms Staff: There is no live-in staff. Continued on LIC809-C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

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: MIRADA MANOR/GREENLEAF	FACILITY NUMBER: 306006320
	VISIT DATE: 09/27/2023

NARRATIVE

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Bathrooms:
Facility has two full bathrooms. All bathrooms have a working toilet, wash basin, walk in shower.

Linens & Hygiene Supplies:
Adequate supply of linen in closet storage throughout the facility.

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 with surplus goods stored in garage.

Smoke Detectors:
Smoke detectors and carbon monoxide alert systems are hardwired, were tested, and found operational. One fire extinguishers mounted in kitchen charged and dated 08/28/2023.

Appliances:
Gas four burner stove, single oven, 2 refrigerator (kitchen and garage), freezer (garage), microwave, washer, and dryer are clean and noted to be operational.

Toxins:
All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to clients are stored and locked underneath kitchen sink, and garage.

Continued on LIC809-C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

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: MIRADA MANOR/GREENLEAF	FACILITY NUMBER: 306006320
	VISIT DATE: 09/27/2023

NARRATIVE

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Water Temperature:
Tested and recorded maintained at a comfortable temperature and the water temperature measures 111.2 Fahrenheit degrees in facility bathrooms.

Medications, First-Aid Kit & Book:
Medication and First Aid kit stored in locked storage cabinet in family room.

Resident & Staff Files:
Records will be kept locked in with medication storage.

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 03/15/23.

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

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: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC809 (FAS) - (06/04)

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