<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006364
Report Date: 07/20/2023
Date Signed: 07/20/2023 04:05:47 PM

Document Has Been Signed on 07/20/2023 04:05 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:LL RESIDENTIAL CAREFACILITY NUMBER:
306006364
ADMINISTRATOR:LUU, THIENFACILITY TYPE:
735
ADDRESS:1515 W. HOLGATE PLTELEPHONE:
(714) 797-6057
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 4CENSUS: DATE:
07/20/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Thien Luu, Administrator;
Max Nguyen, Direct Service Provider		TIME COMPLETED:
04:20 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) Dwayne Mason Jr. and Licensing Program Manager (LPM) Armando Lucero made an announced inspection to the facility for purpose of conducting a pre-licensing inspection. LPA & LPM arrived at the facility at 1:50pm and were greeted and granted entry by designated Administrator (AD) Thien Luu and Direct Service Provider (DSP) Max Nguyen. An application to operate an Adult Residential Care Facility (ARF) for (4) capacity, (4) ambulatory, (0) non-ambulatory, and (0) bedridden clients was received by Community Care Licensing (CCL) on 6/9/2023.

Structure: The facility is a one-story home with four client bedrooms, two bathrooms, living room, kitchen, dining room, an attached two car garage and backyard. The garage is utilized as both storage and an office space for staff. LPA observed a lock on the garage door to prevent client access. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in one of the hallways. There is a back yard with two exit gates on each side of the house. There is one shaded seating area in the backyard. LPA did not observe any obstacles or hazards in the backyard. LPA observed a fireplace covered by an appropriate screen in the living room.

Client Bedrooms: All client bedrooms have the required furnishings. LPA observed all resident beds have linens and blankets. LPA observed all windows were screened.

Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and are stored and locked in cabinets under the kitchen sink.

Medications, First-Aid Kit & Book: Medication is stored in a locked cabinet in the kitchen. First aid kit is stored with the medication. The first aid kit has all the required elements.

Resident & Staff Files: Records are kept locked in the garage.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: LL RESIDENTIAL CARE
FACILITY NUMBER: 306006364
VISIT DATE: 07/20/2023
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
26
27
28
29
30
31
32
Fire Extinguisher: LPA observed the fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone. LPA observed a service tag for the fire extinguisher which indicates the fire extinguisher was last serviced on 9/15/22.

Reading Material, Games, Equipment & Materials: The facility has activity materials in the TV stand in the living room and stored in a container in the garage. Activity materials include puzzles, coloring books, card/board games, and video games.

Fire clearance: Was approved by a fire inspector of Anaheim Fire Department on 06/27/2023.

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

Bathrooms: All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 110.4 degrees Fahrenheit in bathroom #1 and 111.5 degrees Fahrenheit in the bathroom #2.

Linens & Hygiene Supplies: A supply of extra linen is stored in cabinets in bathroom #2 and in the garage.

Emergency Phone Numbers, Exit Plan & Menu: Posted and available for review an emergency disaster plan with means of exiting and emergency phone numbers listed.

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

Smoke Detectors: Smoke detectors and Carbon Monoxide detectors are stationed throughout the home. Both types of detectors were tested and observed to be 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: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2