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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006387
Report Date: 02/22/2024
Date Signed: 02/22/2024 02:40:03 PM


Document Has Been Signed on 02/22/2024 02:40 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 VILLAFACILITY NUMBER:
306006387
ADMINISTRATOR:PARK, YOUNGFACILITY TYPE:
740
ADDRESS:3411 W BALL ROADTELEPHONE:
(714) 821-9660
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:210CENSUS: 36DATE:
02/22/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Young ParkTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection to follow up on corrections identified during visit on 2/12/2024. 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.

At 1:15 p.m. LPA toured the facility and observed the following:

  • Renovations in resident bedrooms, 118,124,128, 129, 130, 131, 137,138, and 139 have ceased.
  • Water temperature in resident bathrooms 247 and 248 has been adjusted to meet regulation, and tested at 107.6 degree F.
  • Ceiling tiles in the second story are in place and the gap which was visible in the ceiling exposing wood beams has been repaired and is no longer visible.
  • All four guinea pigs observed to be living in a staff office on the second story have been removed and the staff office is now odor free.

Component III: was conducted during this inspection, information provided about how to operate the facility within compliance and reporting requirements.

The facility is ready to be licensed. The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
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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