306006387-2-12-2024-22-AS-CGUZ-D2DVYC-20240212155056

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006387
Report Date: 02/12/2024
Date Signed: 02/12/2024 03:52:06 PM

Document Has Been Signed on 02/12/2024 03:52 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ANAHEIM VILLA		FACILITY NUMBER:	306006387
ADMINISTRATOR:	PARK, YOUNG		FACILITY TYPE:	740
ADDRESS:	3411 W BALL ROAD		TELEPHONE:	(714) 821-9660
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	210	CENSUS: 38	DATE:	02/12/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Young Park		TIME COMPLETED:	04:05 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) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with designated Administrator (AD) Young Park, Executive Director (ED) Darlene Lindley, Assistant Administrator Lea Wine, and Corporate Member Yung Lee. An application to operate a Residential Care Facility for the elderly (RCFE) for (210) capacity, (38) ambulatory, (147) non-ambulatory, and (25) bedridden residents was received by CCL on 7/20/2023. Structure: The facility is a three-story building. The first story consists of the lobby, two staff offices, one medication room, one kitchen, one dining room, and 10 resident bedrooms on the assisted living side. Memory care is also located on the first floor and consists of 30 resident bedrooms, one living room, two communal rooms, one dining room, one medication room, two storage closets, one laundry room, and an enclosed courtyard. Delayed egress was tested and observed to be operable. The second story of the facility consists of one activity room, one staff office, two storage closets, one theater room, one library, and 49 resident bedrooms. The third story consists of one family room, one dining area, one hair salon, two janitors’ closets, one storage closet, one laundry room, and 20 resident bedrooms. All resident bedrooms also contain their own full-size bathroom. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the lobby. There are two courtyards, one is located within memory care and an additional courtyard is on the assisted living side of the facility. There is a shaded seating area and LPA did not observe any obstacles or hazards in the courtyard. Resident Bedrooms Occupied resident bedrooms had the required furnishings and LPA observed beds had linens and blankets. Signal system There is signal system. Signal system was tested and observed to be operable.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANAHEIM VILLA	FACILITY NUMBER: 306006387
	VISIT DATE: 02/12/2024

NARRATIVE

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Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked in the various storage closets located throughout the facility.

Medications, First-Aid Kit & Book:
Medication will be stored in the medication room. First aid kit is stored with medication. The first aid kit has all the required elements.

Resident & Staff Files:
Records will be kept locked in a staff office.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
Fire extinguishers were observed on every floor of the facility and were fully charged with a service tag dated 2/17/24.

Reading Material, Games, Equipment & Materials:
The facility has card games, puzzles, and other recreational materials for the client’s use, stored in the activity room.

Fire clearance:
Was approved by a fire inspector of Anaheim Fire Department on 01/05/2024. Special conditions noted, “Bedridden on first floor only.”

Bedrooms Staff:
There are no staff bedrooms.

Smoke Detectors:

Smoke detectors and carbon monoxide detectors tested operational.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANAHEIM VILLA	FACILITY NUMBER: 306006387
	VISIT DATE: 02/12/2024

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Bathrooms:
All bathrooms have working plumbing. Hot water temperature was tested in five resident bedrooms on the first floor, including memory care and tested between 109.7- and 119.1-degrees Fahrenheit. Hot water temperature was tested in five resident bedrooms on the second story and tested between 93.5-117.1 degrees Fahrenheit. Hot water temperature was tested in two resident bedrooms on the third story and tested between 109.4-120.4 degrees Fahrenheit.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available, means of exiting, and emergency phone numbers. Food menu is available for review.

Food Service:
A supply of 2-day perishable and 7-day of non-perishable food was observed and will be maintained on hand.

Appliances:
Appliance were inspected and observed to be operational.

Licensee to address the following corrections by 02/26/2024:

Renovations were observed to be taking place in resident bedrooms, 118,124,128, 129, 130, 131, 137,138, and 139.
Water temperatures tested at 93.5 degrees F in resident bathrooms 247 and 248. Water temperature to be adjusted to meet regulation of 105 to 120 degrees F.
Ceiling tiles in the second story have been moved or are missing and a gap is visible in the ceiling exposing wood beams and covered by a thin clear plastic sheet.
Four guinea pigs are currently living in a staff office on the second story. Two out of the four guinea pigs were observed to be in a designated guinea pig cage. Two out of four guinea pigs are currently being kept in a collapsible wagon intended for hauling.

LPA will make an additional announced visit to follow-up on corrections listed above. An exit interview was conducted, and a copy of this report was provided to designated AD.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

LIC809 (FAS) - (06/04)

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