<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006441
Report Date: 08/19/2024
Date Signed: 08/19/2024 03:35:14 PM

Document Has Been Signed on 08/19/2024 03:35 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:HAZELWOOD HOME, INCFACILITY NUMBER:
306006441
ADMINISTRATOR/
DIRECTOR:		MANALAD, RONALDFACILITY TYPE:
735
ADDRESS:1180 W HAZELWOOD ST.TELEPHONE:
(714) 398-4409
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: 5DATE:
08/19/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:18 PM
MET WITH:Ronald ManaladTIME VISIT/
INSPECTION COMPLETED:
04:00 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) Jenifer Tirre visited this facility for the purpose of conducting a Change of Corporation/ Ownership Pre-Licensing evaluation. During visit LPA observed five clients in care. Facility is a single story residential home. LPA along with Licensee Ronald Manalad toured facility at 1:33 PM and observed the following:

Structure: Facility is a one story, four bedroom (two private bedrooms and two shared bedrooms) and two bathrooms house with attached garage. Living Room/ Dining Room: Adequate seating is available in the dining oom and living room. Bedrooms Residents: Client's bedrooms meet Licensing requirements. Bathrooms: facility bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars and non-skid surface in the shower. Linens & Hygiene Supplies: Facility has adequate supply of linens, blankets and towels. Facility has hygiene products for each resident. Emergency Phone Numbers and Exit Plan: Facility has Emergency Plan posted on wall. Food Service: Facility has supply of 2 day perishables as well as 7 day non-perishables in pantry and refrigerators, as well as emergency food and water supply. Smoke Detectors: Smoke detectors and carbon monoxide detectors are centrally wired and were tested operational. Facility has two fire extinguishers. Fire extinguishers are mounted and fully charged. Appliances: Facility has operating gas stove, three refrigerators, and microwave. Toxins: LPA observed toxins secured in storage cabinet area and Sharps secured in locked drawer. Water Temperature: Tested and recorded at 106.5 degrees F. in facility bathrooms. Reading Material Games, and Equipment:
facility has exercise equipment, puzzles, watch videos ,coloring books and community outings. Medications, First-Aid Kit & Book: Facility has first aid kit present at the facility with proper components. Facility has a secured location for medications and facility files. Backyard: LPA observed the facility perimeter is secured by wall with a self latching gate on both sides of facility. LPA observed shaded outdoor area.

CONTINUED ON 809C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
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 2
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: HAZELWOOD HOME, INC
FACILITY NUMBER: 306006441
VISIT DATE: 08/19/2024
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
26
27
28
29
30
31
32
Administrator's Certificate observed on wall expiring June 19, 2025

Component III Orientation was completed during this pre licensing visit.

No deficiencies noted during todays visit. The pre-licensing visit has been completed. This location is ready for licensure.


An exit interview was conducted with Licensee and a copy of report was left at facility.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
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: 2 of 2