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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006380
Report Date: 01/03/2024
Date Signed: 01/03/2024 03:22:45 PM

Document Has Been Signed on 01/03/2024 03:22 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:HPNB RESIDENTIAL CAREFACILITY NUMBER:
306006380
ADMINISTRATOR:AHLUWALIA, ANAMIKAFACILITY TYPE:
735
ADDRESS:709 S PLYMOUTH PL.TELEPHONE:
(714) 866-9108
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 4CENSUS: 0DATE:
01/03/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Administrator - Anamika Ahluwalia;
Licensee - Anish Gore		TIME COMPLETED:
03:35 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 inspection. LPA arrived at the facility and was greeted and granted entry by the Licensee Anish Gore and designated Administrator (AD) Anamika Ahluwalia. An application to operate an Adult Residential Facility (ARF) for (4) capacity, (4) ambulatory, (0) non-ambulatory, and (0) bedridden clients was received by CCL on 7/10/2023.

Structure:
The facility is a two-story home with four resident bedrooms, two bathrooms, living room, kitchen, dining area, backyard and attached two car garage. LPA observed the facility to be clean and sanitary. There is a back yard with two exit gates on each side of the house. There is a shaded seating area in the backyard. LPA did not observe any obstacles or hazards in the backyard.

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:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked in a closet in the entryway.

Medications, Files, First-Aid Kit & Book:
Medication/Files will be stored in a locked hallway cabinet. First aid kit/book are stored in the living room.

Fire Extinguisher:
All fire extinguishers are fully charged. The service tag indicates it was last serviced on 1/2/2024
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2024
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: HPNB RESIDENTIAL CARE
FACILITY NUMBER: 306006380
VISIT DATE: 01/03/2024
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Activity Materials:
The facility has books, board games, art supplies and more for client use.

Fire clearance:
Was approved by a fire inspector of Anaheim Fire Department on 7/20/2023.

Component III:
Information about operating the facility within compliance was provided.

Bathrooms:


All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 112.5 degrees Fahrenheit in the downstairs bathroom and 120 degrees Fahrenheit in the upstairs bathroom. LPA suggested facility maintains a water log to monitor water temperatures.

Linens & Hygiene Supplies:
A supply of extra linen and hygiene products are stored in the hallway as well as in each client’s closet.

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

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

Smoke Detectors:
Dual Smoke/Carbon Monoxide detectors tested operational.

Appliances:
Gas five burner stove/oven, refrigerators, dishwasher, 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 and Component III presentation were provided to designated AD.

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

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC809 (FAS) - (06/04)
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