306006403-3-15-2024-22-AS-CGUZ-D3DU9H-20240315152311

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006403
Report Date: 03/15/2024
Date Signed: 03/15/2024 03:23:25 PM

Document Has Been Signed on 03/15/2024 03:23 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:	ENDOR CARE HOME		FACILITY NUMBER:	306006403
ADMINISTRATOR:	GARCIA, CRYSTAL		FACILITY TYPE:	735
ADDRESS:	760 S. FAIRWAY LANE		TELEPHONE:	(714) 300-9512
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92807
CAPACITY: 6		CENSUS: 0	DATE:	03/15/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Mitra Dixon		TIME COMPLETED:	03:40 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 Licensee Mitra Dixon. An application to operate an Adult Residential Facility (ARF) for (6) capacity, (4) ambulatory, (2) non-ambulatory, and (0) bedridden clients was received by CCL on August 21, 2023. Structure: The facility is a one-story house with four client bedrooms, two bathrooms, two living room areas, two dining areas, a kitchen, and attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility posted in the entranceway. There is a backyard with a designated exit gate on one side of the house. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard. Resident Bedrooms All client bedrooms had the required furnishings. LPA observed all beds had linens and blankets. Signal system There is no signal system. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and will be stored and locked in the storage cabinet underneath the kitchen sink. Resident & Staff Files: Records will be kept in a locked cabinet.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

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: ENDOR CARE HOME	FACILITY NUMBER: 306006403
	VISIT DATE: 03/15/2024

NARRATIVE

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

Pool/Jacuzzi:
The backyard has an in-ground swimming pool and jacuzzi. Swimming pool and jacuzzi were observed to be inaccessible by mesh fencing. Fencing measured to be five feet and two inches in height. Fencing door swings away from the pool and is self-latching.

Fire Extinguisher:
Fire extinguisher is fully charged with service tag dated 9/20/2023.

Reading Material, Games, Equipment & Materials:
The facility will provide activity books, arts and crafts supplies, board games, puzzles, and other recreational materials.

Fire clearance:
Was approved by a fire inspector of Anaheim Fire Department on 12/28/2023. Special conditions noted, “2 non-ambs in room 1.”

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Bedrooms Staff:
There is no staff bedroom.

Bathrooms:
All bathrooms have working plumbing. Hot water measured between 105.8- and 113.3-degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

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: ENDOR CARE HOME	FACILITY NUMBER: 306006403
	VISIT DATE: 03/15/2024

NARRATIVE

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

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

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas burner stove, dishwasher, refrigerator, microwave, washer, and dryer are operational.

Facility sketch labels the second living room area as “staff area” however, Licensee stated that the area is for common use and will update and resubmit facility sketch to reflect the area as a second living room space. The Licensee 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 provided to Licensee.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

LIC809 (FAS) - (06/04)

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