306006452-4-22-2024-22-AS-JALE-D4KRCC-20240422125407

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006452
Report Date: 04/22/2024
Date Signed: 04/22/2024 12:54:21 PM

Document Has Been Signed on 04/22/2024 12:54 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:	ANAHEIM PALACE		FACILITY NUMBER:	306006452
ADMINISTRATOR:	CHON, CHRISTINE M		FACILITY TYPE:	740
ADDRESS:	525 W. LA PALMA AVE		TELEPHONE:	(626) 252-7287
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY:	199	CENSUS: 181	DATE:	04/22/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Christine Chon, Eric Chang		TIME COMPLETED:	01:05 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) Joseph Alejandre conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA met with Administrator Christine Chon and Eric Chang and toured the facility. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to CCL on October 30, 2023. The facility is to have a capacity of 199, of which 194 can be nonambulatory and 5 bedridden. Applicant has requested a hospice waiver for 25 residents. Facility phone number 714-459-3353. LPAs observed the following. Structure: The facility is a three story building with an interior courtyard with a fountain and an attached parking garage. The fountain is surrounded by flowers and not accessible to residents. Facility has 112 resident rooms. Each resident room has it's own bathroom. There is an outdoor patio at the back of the building for residents to sit outside. The back patio and interior courtyard both have shaded areas for resident to sit outside. There are 5 stairwells in the building. LPA observed all 5 stairwells had an emergency evacuation chair. LPA observed the PUB 475 poster posted in the entry way of the facility. LPA observed a sitting room with books and places to sit next to the main entrance of the facility. Air/Heating: Central air/heating system installed in the building. Resident Bedrooms: All resident bedrooms are spacious and will easily accommodate the residents' belongings. All resident rooms had the required furnishings. There are resident rooms on all three floors of the building. Per fire clearance, bedridden is only to be allowed on the fist floor. Memory care is on the first and second floor. The third floor is for ambulatory residents only.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANAHEIM PALACE	FACILITY NUMBER: 306006452
	VISIT DATE: 04/22/2024

NARRATIVE

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Bathrooms:
All resident bathrooms inspected were clean and operational.

Linens & Hygiene Supplies:
Adequate supply of linen stored throughout the facility.

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 in advance.

Food Service:
LPA observed the kitchen is clean and operational. LPA observed a 2 day perishable and a 7-day non-perishable food supply on hand.

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors/carbon monoxide detectors tested operational. There are fire extinguishers mounted throughout the facility on each floor. All fire extinguishers are fully charged.

Appliances:
All appliances in the kitchen are clean and operational. All washers and dryers in the laundry room which is located in the parking garage are operational. The laundry room is off limits to residents.

Toxins:
All cleaning supplies and chemicals are kept locked in storage closets throughout the facility.

Water Temperature:
Hot water measured in resident bathrooms measured between 104.0 to 120.5 degrees Fahrenheit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANAHEIM PALACE	FACILITY NUMBER: 306006452
	VISIT DATE: 04/22/2024

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Medications, First-Aid Kit & Book:
The first aid kit and the first aid manuals are stored in the medication room on the first floor and in memory care. All the first aid kits had the required elements. Medication is kept locked in the medication room.

Resident & Staff Files:
The Resident and Staff Records will be kept locked in the facility office.

Reading Material, Games, Equipment & Materials:
There is an activity room on the third floor. There is a TV in the movie room on the first floor. There are board games, card games and arts and craft supplies. The monthly activity calendar is posted in the main lobby and dining room.

Fire clearance:
Fire Clearance approved by Anaheim Fire Department, fire Inspector Adam Graef on December 15, 2023.
The facility is approved for delayed egress and secured perimeter for the memory care unit on the first and second floors.

Component III:
Component three was completed with the Licensee's representative (Administrator).
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The facility is ready to be licensed. Administrator 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 Administrator.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

LIC809 (FAS) - (06/04)

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