306006378-10-12-2023-22-AS-DLMN-CWJUJ4-20231012153656

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006378
Report Date: 10/12/2023
Date Signed: 10/12/2023 03:37:19 PM

Document Has Been Signed on 10/12/2023 03:37 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:	LANTANA HOME		FACILITY NUMBER:	306006378
ADMINISTRATOR:	SHARMA, NARESH		FACILITY TYPE:	735
ADDRESS:	7704 LANTANA DR		TELEPHONE:	(714) 858-2351
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 4		CENSUS:	DATE:	10/12/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:23 PM
MET WITH:	Naresh Sharma - Adminstrator		TIME COMPLETED:	03:50 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. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility at 1:20 pm and was greeted and granted entry by designated Administrator (AD) Naresh Sharma. An application to operate an Adult Residential Facility (ARF) for (4) capacity, (4) ambulatory, (0) non-ambulatory, and (0) bedridden clients was received by Community Care Licensing (CCL) on 7/3/2023. Structure: The facility is a one-story home with four resident bedrooms, two bathrooms, living room, kitchen, dining room, backyard and detached two car garage. There is one exit gate in the back yard. Based on review of facility sketch, LPA noted that there are no arrows pointing to the backyard exit gate. Administrator stated they will update the facility sketch to show the exit path in the backyard and email the updated sketch to LPA and CAB Analyst. The facility has patio chairs but no table. LPA also observed the following items in the backyard: a pile of cardboard boxes next to one of the bushes, a doghouse with chipped paint and warped wood, a crate of unused bathroom tiles, a rusted paint can, unused trash cans and bags of fertilizer that have been ripped open. AD stated the facility has no immediate plans to get a dog. 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 in the garage. Medications, First-Aid Kit & Files: Medication will be stored in a locked cabinet in the hallway. First Aid Kits will be stored with medication and in the kitchen. Records will be kept in a cabinet beneath the medication. Fire Extinguisher: LPA observed fire extinguisher to be fully charged

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

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: LANTANA HOME	FACILITY NUMBER: 306006378
	VISIT DATE: 10/12/2023

NARRATIVE

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Activity Materials: The facility does not have activity materials.

Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 7/25/2023.

Component III: Information provided operating the facility within compliance and reporting requirements.

Bathrooms: The bathrooms have working plumbing. Hot water measured at 116.6 degrees Fahrenheit in the master bathroom and 109.9 degrees Fahrenheit in the bathroom between the kitchen and bedroom 2.

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

Emergency Phone Numbers, posted and available for review. Facility does not have a menu posted.

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

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

Appliances: Gas stove, oven, refrigerator, dish washer, microwave, washer, and dryer are operational.

Based on observations from today’s visit the following corrections need to be made prior to receiving license:

1. Facility must have, on hand, their Plan of Operation and Infection Control Plan

2. Facility must provide a table in outdoor patio in order to provide a comfortable outdoor seating/activity area

3. Facility must clear the backyard of the following: the pile of cardboard boxes, doghouse, crate of unused bathroom tiles, rusted paint can, unused trash cans and the bags of fertilizer that have been ripped open

4. Facility must send via email an updated facility sketch reflecting the backyard exit route and assembly point to their CAB Analyst and LPA

5. Facility must provide activity supplies and post menu in facility for view

Administrator stated they will notify LPA upon completion of the previously mentioned corrections. An exit interview with AD Naresh Sharma was conducted. A copy of this report was provided.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC809 (FAS) - (06/04)

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