306006372-10-9-2023-22-AS-DLMN-CWFNQT-20231009104029

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006372
Report Date: 10/09/2023
Date Signed: 10/09/2023 10:41:53 AM

Document Has Been Signed on 10/09/2023 10:41 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:	HIGHTOWER RESIDENTIAL CARE		FACILITY NUMBER:	306006372
ADMINISTRATOR:	ARONNE, CELFA		FACILITY TYPE:	740
ADDRESS:	23391 CAVANAUGH ROAD		TELEPHONE:	(949) 500-3760
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 4	DATE:	10/09/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Celfa Aronne - Administrator		TIME COMPLETED:	10:55 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 (change of ownership) with clients in care. LPA arrived at the facility at 8:40 am and was greeted and granted entry by designated Administrator (AD) Celfa Aronne. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden clients was received by Community Care Licensing (CCL) on 6/28/2023. Structure: The facility is a one-story home with four resident bedrooms, two bathrooms, two staff rooms, living room, kitchen, dining room, activities room, an attached one car garage and backyard. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the living room. There is a back yard with two exit gates. The facility has one shaded seating area. LPA did not observe any obstacles or hazards in the backyard. Client Bedrooms: All resident bedrooms had the necessary furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked under the kitchen sink and in the garage. Medications, First-Aid Kit & Book: Medication is stored in a locked cabinet in the hallway. The First Aid Kit is mounted on the wall in the entryway. The facility was advised to print out a copy of the 20-page American Red Cross PDF Manual. Resident & Staff Files: Records are kept in the closet with the medication. LPA reviewed two staff files and two out of four resident files.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

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: HIGHTOWER RESIDENTIAL CARE	FACILITY NUMBER: 306006372
	VISIT DATE: 10/09/2023

NARRATIVE

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Fire Extinguisher: LPA observed the fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone. LPA observed the service tag on the fire extinguisher which indicates it was last serviced on 12/9/22

Reading Material, Games, Equipment & Materials: The facility has coloring books, puzzles, exercise equipment and planned group activities.

Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 08/01/2023.

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

Bathrooms: The bathrooms have working plumbing. Hot water measured at 113 degrees Fahrenheit in both bathrooms

Linens & Hygiene Supplies: A supply of extra linen and hygiene supplies are stored in the hallway closet

Emergency Phone Numbers, Exit Plan & 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 were observed to be dual Smoke & Carbon Monoxide detectors that are stationed throughout the home. The dual detectors were tested and observed to be operational.

Appliances: Gas four burner stove with 1 oven, 1 refrigerator, dish washer, microwave, washer, and dryer are operational. Administrator stated that they are working with the previous owner to remove the unused appliances in the garage. Residents do not have access to garage.

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: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

LIC809 (FAS) - (06/04)

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