306006416-3-21-2024-22-AS-DLMN-D3KMD8-20240321093043

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006416
Report Date: 03/21/2024
Date Signed: 03/21/2024 09:31:11 AM

Document Has Been Signed on 03/21/2024 09:31 AM - 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:	ABUNDANT GRACE CARE VILLA		FACILITY NUMBER:	306006416
ADMINISTRATOR:	DOMPREH-MENSAH, THERESA		FACILITY TYPE:	740
ADDRESS:	9672 COLONY STREET		TELEPHONE:	(657) 201-3142
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	6	CENSUS: 0	DATE:	03/21/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:26 AM
MET WITH:	Thersa Dompreh-Mensah and James Mensah		TIME COMPLETED:	09:45 AM

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) 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 Administrator Theresa Dompreh-Mensah and Vice-President, James Mensah. An application to operate a Residential Care Facility for the Elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden residents was received by Community Care Licensing (CCL) on 9/13/2023. The facility is a one-story home with three shared resident bedrooms, three bathrooms, living room, dining room, kitchen, office/staff room, attached two car garage and backyard. LPA did not observe any obstructions blocking the exit gate or obstacles or hazards in the backyard. Client Bedrooms have all the necessary requirements including bed, chair, storage for clothing and ample lighting. LPA observed all windows were screened. All bathrooms have working plumbing and designated hand washing posters. Hot water initially measured above 120 degrees Fahrenheit. AD stated they had adjusted the hot water heater prior to the inspection. LPA observed the hot water to be within the correct range during the inspection. LPA issued a technical assistance advising the AD to maintain a daily water log to ensure proper temperatures are maintained. LPA observed the fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone. LPA observed a service tag indicating the fire extinguisher was serviced on 9/13/2023. Medications, First-Aid Kit, Resident & Staff Files will be locked in cabinets in the kitchen. The fire clearance was approved by a fire inspector of Orange County Fire Authority on 12/1/2023. A supply of extra linens is stored in a closet in the hallway.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ABUNDANT GRACE CARE VILLA	FACILITY NUMBER: 306006416
	VISIT DATE: 03/21/2024

NARRATIVE

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LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and are stored and locked in the kitchen, bathrooms and garage.

Emergency Phone Numbers, and Exit Plan are all posted and available for review. LPA observe an 8.5" x 11" PUB 475 posted. AD placed an order for a 20" x 26" print of the PUB475 during the inspection.

Smoke and Carbon Monoxide detectors are stationed throughout the home and are wired together. Both types of detectors were tested and noted as operational.

Operational appliances include a gas stove, oven, two refrigerators, dishwasher, microwave, washing machine and dryer.

The facility has a cabinet of activity supplies including but not limited to arts and crafts, board games and more.

LPA reviewed and provided Administrator with the Component III presentation to offer information and resources regarding maintaining facility compliance.

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.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC809 (FAS) - (06/04)

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