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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006405
Report Date: 08/19/2024
Date Signed: 08/19/2024 03:32:57 PM

Document Has Been Signed on 08/19/2024 03:32 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HILLS OF CANADIAN, THEFACILITY NUMBER:
306006405
ADMINISTRATOR/
DIRECTOR:		MIRANDA, ROSENDO CARLOFACILITY TYPE:
740
ADDRESS:3159 CANADIAN DRIVETELEPHONE:
(714) 430-7672
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 4DATE:
08/19/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Maricel Nepomuceno, Rosendo Carlo MirandaTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an announced visit to the facility to conduct the pre-licensing inspection. LPA met with Applicant Maricel Nepomuceno and toured the facility.
An initial application to operate an Residential Care Facility for the Elderly (RCFE) was submitted to CCL on June 13, 2024. The facility is to have a capacity of 6 non-ambulatory residents with zero (0) bedridden. LPA observed the following. This is a change of ownership application with residents in care. Facility phone number is 714-617-4516. LPA observed the PUB 475 poster posed in the entry way.

Structure:
The facility is a single story house with an attached 2 car garage with 5 bedrooms (room 1 is for staff, bedrooms 4, 5 can be shared), 4 bathrooms, living room with a screened fireplace, dining room and a kitchen.

Air/Heating:
Central air/heating system installed with a central panel to control entire house. The air conditioning was operating during the visit.

Resident Bedrooms:
There are 4 resident Bedrooms. The bedrooms are spacious and will easily accommodate the residents' belongings. All resident rooms had the required furnishings and linens.

Medications, First-Aid Kit & Book:
The first aid kit and the first aid manual are stored in the dining room. The first aid kit has all the required elements. Medications will be stored in the closet next to the kitchen and kept locked.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HILLS OF CANADIAN, THE
FACILITY NUMBER: 306006405
VISIT DATE: 08/19/2024
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Reading Material, Games, Equipment & Materials:
Magazines and games are stored in the living room. There is a large screen TV mounted in the living room. At this time the facility does not have internet access.

Fire clearance:
Fire Clearance approved by the Costa Mesa Fire Department Inspector Arnold Antonio on July 10, 2024.

Component III:
Component three waived. Applicant is a Licensee/Administrator of a Licensed Facility.

The facility is ready to be licensed.

Applicant was informed today that the final approval will be processed by CAB (Central Applications Bureau) in Sacramento.

Exit interview was conducted and a copy of this report was left with the applicant.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HILLS OF CANADIAN, THE
FACILITY NUMBER: 306006405
VISIT DATE: 08/19/2024
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Bathrooms:
All four bathrooms are clean and operational.

Linens & Hygiene Supplies:
Adequate supply of linen stored in hall closet. Extra hygiene supplies are stored in the garage.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food served for one week.

Food Service:
LPA observed a two day perishable and a seven day non-perishable food supply on hand in the kitchen in the kitchen.

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors/carbon monoxide detectors tested operational. The fire extinguisher in the kitchen and the fire extinguisher in the hallway are fully charged.

Appliances:
There is a 5 burner gas stove, an oven, microwave oven, dishwasher and refrigerator in the kitchen. The washer and dryer are in the garage. All appliances are clean and operational.

Toxins:
The cleaning supplies are kept locked in the garage.

Water Temperature:
Hot water measured 116.8 degrees Fahrenheit in all bathrooms.

Resident & Staff Files:
The Resident and Staff Records will be kept locked in the closet next to the kitchen.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC809 (FAS) - (06/04)
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