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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006363
Report Date: 12/04/2023
Date Signed: 12/04/2023 11:26:19 AM

Document Has Been Signed on 12/04/2023 11:26 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:QUEENS HOME 3FACILITY NUMBER:
306006363
ADMINISTRATOR:MAGHBOULEH, KATHYFACILITY TYPE:
740
ADDRESS:14752 HOLT AVETELEPHONE:
(714) 731-6385
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 15CENSUS: 11DATE:
12/04/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kathy MaghboulehTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at the facility and was greeted and granted entry by staff. LPA met with Kathy Maghbouleh, Director/Administrator.

A change of ownership application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (15) capacity, (0) ambulatory, (15) non-ambulatory, and (0) bedridden residents was submitted to CCL on 05/22/2023.

Structure:
The facility is a two unit one-story house each as unit A and Unit B. Unit A has 4 resident bedrooms, 1 staff bedroom, 2 full bathrooms, a living room, a dining room, and a kitchen. Unit B has 6 resident bedrooms, 1 staff bedroom, 3 full bathrooms, a living room, a dining room, and a kitchen. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with an exit walkway on one side of the house with 2 covered seating patios for the residents. Air/Heating:
Central air/heating system installed with a central panel to control entire house in each unit. Bedrooms Residents: Bedrooms will accommodate 15 residents combined in both units. Unit A will accommodate 6 residents with 2 private and 2 shared bedrooms. Unit B will accommodate 9 residents with 3 private and 3 shared bedrooms. Bedrooms Staff: Unit A bedroom #1 designated for awake-staff and unit B bedroom #7 designated for awake-staff. Bathrooms: All bathrooms have a working toilet, wash basin, and walk-in shower. Linens & Hygiene Supplies: Adequate supply of linen stored in bedroom hallway storage in both units. 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.

Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023
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: QUEENS HOME 3
FACILITY NUMBER: 306006363
VISIT DATE: 12/04/2023
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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. Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired, were tested, and found operational. Appliances:
Unit a has 5 gas burner stove, single oven, 1 refrigerator, microwave, washer, and dryer, unit B has a 4 gas burner stove, single oven, 2 refrigerators, microwave, washer and dryer. All were noted to be clean and operational. Toxins: All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are stored and locked underneath kitchen sink and locked storage in both units. Water Temperature: Tested and recorded maintained at a comfortable temperature and the water temperature measures 119.8 Fahrenheit degrees in unit A and 108.9 Fahrenheit degrees in unit B in facility bathrooms. Medications, First-Aid Kit & Book: Medication and first aid kit/book are stored and locked in a storage cabinet located in kitchen in both units. Resident & Staff Files: Records will be kept locked in office space in both units. Each unit has an office space. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the resident’s use, commensurate with the plan of operation. Fire clearance: Was approved on August 29, 2023. 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: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023
LIC809 (FAS) - (06/04)
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