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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006339
Report Date: 09/05/2023
Date Signed: 09/05/2023 03:19:43 PM

Document Has Been Signed on 09/05/2023 03:19 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:OC VILLAS - LINDA VISTAFACILITY NUMBER:
306006339
ADMINISTRATOR:ROMAN, ELSAFACILITY TYPE:
740
ADDRESS:1184 N LINDA VISTA STTELEPHONE:
(562) 607-4077
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY: 6CENSUS: DATE:
09/05/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Elsa Roman - AdministratorTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility at 1:10 pm and was greeted and granted entry by designated Administrator (AD) Elsa Roman. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden clients was received by Community Care Licensing (CCL) on 4/4/2023.

Structure:
The facility is a one-story home with six resident bedrooms, two resident bathrooms,family room, living room, kitchen, dining room, an attached two car garage and backyard. All doors leading to the backyard are equipped with alarms to notify staff when they are opened. AD notified LPA that the 20” x 26” PUB 475 has been ordered. There is a back yard with one exit gate. The facility has two shaded sitting areas. LPA did not observe any obstacles or hazards in the backyard. The facility has a pool that is enclosed by a fence.

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

Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked under the kitchen sink and in the garage.

Medications, First-Aid Kit & Book: Medication and First Aid Kit will be stored in a locked cabinet in the dining room. The AD showed proof of purchase for a copy of a full First Aid Manual.

Resident & Staff Files: Records will be kept in a cabinet in the dining room.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023
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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: OC VILLAS - LINDA VISTA
FACILITY NUMBER: 306006339
VISIT DATE: 09/05/2023
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Fire Extinguisher: LPA observed one fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone. LPA observed the proof of purchase for the fire extinguisher which indicates it was purchased on 4/27/23

Reading Material, Games, Equipment & Materials: The facility has art supplies in a cabinet in the dining room.

Fire clearance: Was approved by a fire inspector of Orange Fire Department on 04/17/2023.

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

Bathrooms: The bathrooms have working plumbing. Hot water measured at 108.4 degrees Fahrenheit in the Private Bathroom and 109.4 degrees Fahrenheit in the Common Bathroom

Linens & Hygiene Supplies: A supply of extra linen and hygiene supplies is stored in the hallway closet

Emergency Phone Numbers, Exit Plan & Menu: Posted and available for review

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

Smoke Detectors: Detectors were observed to be dual smoke and carbon monoxide detectors that are wired through the home. Detectors were tested and 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: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC809 (FAS) - (06/04)
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