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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006437
Report Date: 04/03/2024
Date Signed: 04/03/2024 09:44:11 AM


Document Has Been Signed on 04/03/2024 09:44 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:AA PLUS CARE HOMEFACILITY NUMBER:
306006437
ADMINISTRATOR:YAMASHIRO, SHELLYFACILITY TYPE:
740
ADDRESS:4458 VIA DEL VALLETELEPHONE:
(714) 463-4194
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 5DATE:
04/03/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Shelly Yamashiro - Administrator, Kelly Ho - LicenseeTIME COMPLETED:
10:00 AM
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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 Administrator Shelly Yamshiro and Licensee Kelly Ho. An application to operate a Residential Care Facility for the Elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden clients was received by Community Care Licensing (CCL) on 10/18/2023.

The facility is a one-story home with four client bedrooms, two bathrooms, living room, den, dining room, kitchen, covered patio, backyard and 2-car garage.



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 measured at 115.8 degrees Fahrenheit and 118 degrees Fahrenheit in the bathrooms.

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 extinguisher was last serviced in October of 2023.

Medication and First-Aid Kit will be locked in a closet in the hallway. Resident & Staff Files will be locked in drawers at at desk in the dining area.

The fire clearance was approved by a fire inspector of Orange County Fire Authority on 2/13/2024.

LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and are stored and locked under the kitchen sink and in the garage.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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: AA PLUS CARE HOME
FACILITY NUMBER: 306006437
VISIT DATE: 04/03/2024
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A supply of extra linens is stored in a closet in the hallway.

Emergency Phone Numbers, Exit Plan, Activity Calendar and Menu are all posted and available for review. LPA observed other necessary postings in the living room.

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.

LPA reviewed and provided Administrator and Licensee 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 LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
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