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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006379
Report Date: 10/04/2023
Date Signed: 10/04/2023 03:44:29 PM


Document Has Been Signed on 10/04/2023 03:44 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:WEST ORANGE SENIOR LIVINGFACILITY NUMBER:
306006379
ADMINISTRATOR:FRANCISCO, ANALIEFACILITY TYPE:
740
ADDRESS:3359 W ORANGE AVETELEPHONE:
(626) 561-8029
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 3DATE:
10/04/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Analie Francisco - AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced visit to the facility for purpose of conducting a pre-licensing (change of ownership) inspection. LPA arrived at the facility at 12:45 pm and was greeted and granted entry by designated Administrator (AD) Analie Francisco. An application to change ownership of a Residential Care Facility for the Elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden clients was received by Community Care Licensing (CCL) on 7/10/23.

Structure: The facility is a one-story home with two private resident rooms, 2 shared resident rooms, three bathrooms, two living rooms, two dining rooms, kitchen, caregiver room, garage, backyard and front yard. LPA observed the front yard to be enclosed by a wall and gate. LPA did not observe any obstacles or hazards in the front or back yard.

Client Bedrooms: All resident bedrooms had the required 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 in the garage.

Medications, First Aid and Files: Resident & Staff files, Medication and First Aid Kit will be stored in a locked cabinet in Living Room 1. The first aid kit has all the required elements.

Fire Extinguisher: LPA observed two fire extinguishers to be fully charged as indicated by the arrow pointing in the green zone. LPA observed the service tag indicating the extinguishers were last serviced on 4/6/23.

Activity Materials: Books, games, puzzles, exercise equipment and art supplies that are stored in Living Room 2
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: WEST ORANGE SENIOR LIVING
FACILITY NUMBER: 306006379
VISIT DATE: 10/04/2023
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Bathrooms: The bathrooms have working plumbing. Hot water measured at 118.3 degrees Fahrenheit in bathroom 1, 119.8 degrees Fahrenheit in bathroom 2 and 119.3 degrees Fahrenheit in bathroom 3. LPA advised AD to monitor the hot water closely on hot days since the temperatures are close to 120 degrees Fahrenheit.

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

Smoke Detectors: Smoke detectors were observed to be dual Smoke & Carbon Monoxide detectors that are stationed throughout the facility. All detectors were tested and observed to be operational.

Appliances: Gas five burner stove with oven, two refrigerators, dish washer, microwave, washer, and dryer are operational.

Upon review of the approved facility sketch, LPA observed the approved exit plan indicates that, in an emergency, the residents will evacuate through a gate to the side of the garage. LPA observed a brick wall to the side of the garage. LPA took photos of the wall and the approved facility sketch to send to the Centralized Applications Bureau (CAB). Facility is awaiting guidance from CAB regarding how to proceed to correct the approved facility sketch.

Exit interview was conducted and a copy of this report was provided to designated AD.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC809 (FAS) - (06/04)
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