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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006410
Report Date: 10/26/2023
Date Signed: 10/26/2023 02:01:29 PM

Document Has Been Signed on 10/26/2023 02:01 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:UNIQUE CARE 1FACILITY NUMBER:
306006410
ADMINISTRATOR:NASSIF, JOSEPHFACILITY TYPE:
735
ADDRESS:127 W BORROMEO AVETELEPHONE:
(657) 276-2105
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 6DATE:
10/26/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Joseph Nassif - LicenseeTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection. LPA arrived and was greeted and granted entry by designated Administrator (AD) Joesph Nassif. An application to operate an Adult Residential Facility (ARF) for (6) capacity, (5) ambulatory, (1) non-ambulatory, and (0) bedridden clients was received by Community Care Licensing (CCL) on 8/14/2023.

Structure: The facility is a one-story home with six client bedrooms, three bathrooms, staff bedroom, living room, TV room, kitchen, dining room, an attached two car garage, shaded patio and backyard. The garage is utilized as both storage and an office space for staff. LPA observed a lock on the garage door to prevent client access. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entryway. There is a back yard with one exit gate. There is one shaded seating area in the backyard. LPA did not observe any obstacles or hazards in the backyard.

Client Bedrooms: All client bedrooms have the required furnishings. LPA observed all resident beds have linens and blankets. LPA observed all windows were screened.

Toxins: LPA observed cleaning chemicals to be stored and locked in cabinets in the garage.

Medications, First-Aid Kit: Medication/first aid kit are stored in a locked cabinet in hallway near the TV room.

Resident & Staff Files: Records will be locked in the garage.

Fire Extinguisher: LPA observed the fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone. LPA observed a service tag for the fire extinguisher which indicates the fire extinguisher was last serviced on 5/11/2023.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2023
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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: UNIQUE CARE 1
FACILITY NUMBER: 306006410
VISIT DATE: 10/26/2023
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Activities: The facility has several planned activities including but not limited to outdoor games and exercise, board games, puzzles, fairs/park visits, reading, sing-a-longs and more.

Fire clearance: Was approved by a fire inspector of City of Placentia Fire Department on 10/3/2023.

Bathrooms: All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 116.6 degrees Fahrenheit in bathroom in bedroom #7, 107.6 degrees Fahrenheit in the bathroom nearest bedroom #5 and 116.2 degrees Fahrenheit in the bathroom nearest to bedroom #2.

Linens & Hygiene Supplies: A supply of extra linen is stored in cabinets in the hallway. Extra hygiene supplies are stored in the garage.

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

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

Smoke Detectors: Smoke detectors and Carbon Monoxide detectors are stationed throughout the home. Both types of detectors were tested and observed to be operational.

Appliances: Gas five burner stove with 1 oven, 2 refrigerators, dish washer, 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 was provided to designated AD
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC809 (FAS) - (06/04)
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