306006344-6-23-2023-22-AS-LMAZ-CT3VDM-20230623162058

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006344
Report Date: 06/23/2023
Date Signed: 06/23/2023 04:21:43 PM

Document Has Been Signed on 06/23/2023 04:21 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:	COGIR OF BREA		FACILITY NUMBER:	306006344
ADMINISTRATOR:	FAYE, SAMUEL		FACILITY TYPE:	740
ADDRESS:	700 MADISON WAY		TELEPHONE:	(714) 681-0105
CITY:	BREA	STATE: CA	ZIP CODE:	92821
CAPACITY:	110	CENSUS: 0	DATE:	06/23/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Samuel Faye		TIME COMPLETED:	02:00 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) Lydia Martinez conducted an announced Pre-Licensing visit and was greeted and granted entry into the facility by Designated Administrator Samuel Faye. The initial Application to operate an Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 04/12/2023 for a capacity of 110 non-Ambulatory residents, of which 12 may be bedridden. A tour of the physical plant was conducted inside and out with Mr. Faye. The following was observed: No resident were present during today's visit as facility is a brand new facility. Structure: The facility is designed as an apartment Assisted Living and Memory Care with two floors with a restaurant style kitchen/food prep area, Lobby, Activity Room/Art Studio, Bistro, Medication Room, Movie Theater, Fitness Room, Beauty Salon, Dining Room, and a Courtyard with patio tables and chairs. The resident’s bedrooms are spacious and will easily accommodate the residents furnishings. Air/Heating: Central air/heating system installed with a central panel to control each designated section of building. Resident’s bedroom have individual central panel to control entire apartment. Bedrooms Residents: 58 in Assisted Living and 22 in Memory Care for total of 110 non-Ambulatory residents. All bedrooms are equipped with an attached bathroom. Signal System: Call system is in place in each apartment in Assisted Living and Memory Care. Was tested and found to be operational. Bedrooms Staff: No bedroom designated for awake-staff.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: COGIR OF BREA	FACILITY NUMBER: 306006344
	VISIT DATE: 06/23/2023

NARRATIVE

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Bathrooms: All bathrooms have a working toilet, wash basin, grab bars and walk-in shower.

Linens & Hygiene Supplies: Adequate supply of new linen available in storage space of facility.

Ombudsman Poster, Personal Rights and See Something Say Something Poster: Ombudsman poster, Personal Rights and See Something Say Something posters were posted.

Emergency Phone Numbers, Exit Plan & Menu: Posted & readily available for review and Emergency Disaster Plan with means of exiting and emergency phone numbers listed. Evacuation Chairs are in place. Menus posted and available. Menus prepared one week prior and listed for food served for one week.

Generator: Observed during the visit.

Food Service: Adequate supply of 7-day non-perishable and 2-day perishables will be available at all times when residents present.

Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired and tested by outside vendor.

Appliances: Residents apartment are equipped with a refrigerator/freezer and microwave.

Toxins: Several locked closets for storage of toxins and cleaning equipment.

Water Temperature: Is within regulatory requirements of 105 and 120 degrees F.

Medications, First-Aid Kit & Book: Medication, First Aid kit, and First Aid book stored in medication room, inaccessible to residents.

Resident & Staff Files: Records will be kept in business office.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: COGIR OF BREA	FACILITY NUMBER: 306006344
	VISIT DATE: 06/23/2023

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Pool/Jacuzzi & Pets:
No pool or bodies of water observed. Pets will be allowed under 30 lbs.

Fire Extinguisher:
Mounted in hallways and common areas.

Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the residents use, commensurate with the Plan of Operation.

Fire clearance: Granted on 06/07/2023 for 98 non-Ambulatory, and 12 bedridden residents. The following special conditions shown on the approved floor plan: Approved delayed egress and bedridden occupants. Bedridden not to exceed 12 for entire building.

Component III: Component III is waived as Applicant is an existing Administrator.

Designated Administrator was notified that the final application approval will be issued by CAB in Sacramento. The facility meets Title 22 requirements and is ready to be licensed based on LPA's inspection. Exit interview was conducted and a copy of this report will be sent to email on file.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC809 (FAS) - (06/04)

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