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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006370
Report Date: 12/13/2023
Date Signed: 12/13/2023 02:29:34 PM

Document Has Been Signed on 12/13/2023 02:29 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:SEIFERT HOMES INC. - IMPERIALFACILITY NUMBER:
306006370
ADMINISTRATOR:SEIFERT, DEBORAHFACILITY TYPE:
735
ADDRESS:9292 IMPERIAL AVE.TELEPHONE:
(714) 741-4933
CITY:GARDEN GROVESTATE: CAZIP CODE:
92844
CAPACITY: 6CENSUS: 6DATE:
12/13/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:Deborah Seifert - AdministratorTIME COMPLETED:
02:45 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 for a change of ownership. LPA arrived at the facility and was greeted and granted entry by designated Administrator (AD) Deborah Seifert. An application to operate a Adult Residential Facility (ARF) for (6) capacity, (6) ambulatory, (0) non-ambulatory, and (0) bedridden clients was received by Community Care Licensing (CCL) on 6/26/2023.

Structure: The facility is a one-story home with three resident bedrooms, two bathrooms, living room, kitchen, dining room, staff room, backyard and attached two car garage. There are two exit gates in the back yard. The backyard has a seating area.

Client Bedrooms: All resident bedrooms had the necessary furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. Facility has extra chairs in the staff room.

Bathrooms: The bathrooms have working plumbing. Hot water measured at 110.2 degrees Fahrenheit in the common bathroom and 109.2 degrees Fahrenheit in the staff bathroom which residents use if necessary.

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

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

Activity Materials: The facility has a facility calendar with various outings for residents. Facility also has exercise equipment, dolls, electronics and more.

Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored under the kitchen sink and in cabinets in the garage.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2023
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: SEIFERT HOMES INC. - IMPERIAL
FACILITY NUMBER: 306006370
VISIT DATE: 12/13/2023
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Medications, First-Aid Kit & Files: Medication and first aid kit will be stored in a locked cabinet in the kitchen pantry. Records will be kept in the staff room.

Fire Extinguisher: LPA observed the fire extinguishers to be fully charged as indicated by the arrow pointing in the green zone. Extinguishers were serviced on 12/5/2023

Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 8/7/2023.

Component III: Information provided about how to operate the facility within compliance and reporting requirements.

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
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC809 (FAS) - (06/04)
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