306006353-11-30-2023-22-AS-DLMN-CY3PK6-20231130102238

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006353
Report Date: 11/30/2023
Date Signed: 11/30/2023 10:23:08 AM

Document Has Been Signed on 11/30/2023 10:23 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	COLUMNS CARE HOME		FACILITY NUMBER:	306006353
ADMINISTRATOR:	HSI, CATHERINE		FACILITY TYPE:	740
ADDRESS:	17332 LAURIE LN		TELEPHONE:	(732) 589-4692
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY:	6	CENSUS: 5	DATE:	11/30/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Cathy Hsi - Administrator		TIME COMPLETED:	10:40 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) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility and was greeted and granted entry by designated Administrator (AD) Cathy Hsi. An application to operate a Residential Care Facility for the Elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden clients was received by Community Care Licensing (CCL) on 5/4/2023. Structure: The facility is a one-story home with four resident bedrooms, two bathrooms, living room, kitchen, dining room, backyard, staff room, staff bathroom and three car garage. There are two exit gates in the back yard. The latch on one exit gate is slightly rusted. AD stated they will have maintenance person address this. Client Bedrooms: All resident bedrooms had the necessary furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. Bedrooms with doors leading to the backyard also had alarms to notify staff of open doors. Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored under the kitchen sink and above the laundry machines. Medications, First-Aid Kit & Files: Medication will be stored in a locked cabinet in the kitchen. The First Aid Kit had all the required elements and is stored with medication and facility records. Fire Extinguisher: LPA observed the fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone Component III: Information provided about how to operate the facility within compliance and reporting requirements.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

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: COLUMNS CARE HOME	FACILITY NUMBER: 306006353
	VISIT DATE: 11/30/2023

NARRATIVE

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Activity Materials: The facility has exercise equipment, books, card/board games and art supplies.

Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 5/23/2023.

Bathrooms: The bathrooms have working plumbing. Hot water measured at 109.4 degrees Fahrenheit in the common bathroom and 107 degrees Fahrenheit in the bathroom in one of the shared rooms.

Linens: A supply of extra linen is stored in the hallway closet

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

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

Smoke Detectors: Smoke detectors and carbon monoxide detectors were tested and observed to be operational.

Appliances: Gas stove, oven, 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.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC809 (FAS) - (06/04)

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