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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006461
Report Date: 07/01/2024
Date Signed: 07/01/2024 04:56:09 PM

Document Has Been Signed on 07/01/2024 04:56 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:IKSHA HOMES/MAGNOLIAFACILITY NUMBER:
306006461
ADMINISTRATOR/
DIRECTOR:		THEBE, HIMALFACILITY TYPE:
735
ADDRESS:715 S MAGNOLIA AVETELEPHONE:
(323) 899-0859
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 6DATE:
07/01/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Himal Thebe, Smriti ThebeTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Joseph Alejandre conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA met with Applicants Himal Thebe and Smriti Thebe and toured the facility.

An initial application to operate an Adult Residential Facility (ARF) was submitted to CCL on November 20, 2023. The facility is to have a capacity of 6 Ambulatory clients. Facility phone number 714-229-0198. LPA observed the following. This is a change of ownership application with clients in care.

Structure:
The facility is a single story house with an attached 2 car garage with 6 bedrooms, 2 bathrooms, dining room, a kitchen, living room and an office.

Air/Heating:
Central air/heating system installed with a central panel to control entire house. The air conditioning was operating during the visit.

Client Bedrooms:
There are 6 client Bedrooms and each bedroom is private. The bedrooms are spacious and will easily accommodate the clients' belongings. All client rooms had the required furnishings and linens.

Medications, First-Aid Kit & Book:
The first aid kit and the first aid manual are stored in the garage. The first aid kit has all the required elements. Medications are stored in a kitchen cabinet and kept locked.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2024
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 3
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: IKSHA HOMES/MAGNOLIA
FACILITY NUMBER: 306006461
VISIT DATE: 07/01/2024
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Bathrooms:
Both bathrooms have a working toilet, wash basin and walk in shower. Both bathrooms are clean and operational.

Linens & Hygiene Supplies:
Adequate supply of linen stored in hall closet. Extra hygiene supplies are stored in the garage.

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 prior and listed for food served for one week.

Food Service:
There is 2-day perishable and 7-day non-perishable food supply on hand. There is an emergency supply of food and water stored in the garage.

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors/carbon monoxide detectors tested operational. The fire extinguisher in the kitchen is fully charged.

Appliances:
There is a 4 burner gas stove which includes an oven, microwave oven and refrigerator in the kitchen. The washer and dryer are in the garage. All appliances are clean and operational.

Toxins:
The cleaning supplies are kept locked under the kitchen sink and extra supplies are kept locked in the garage.

Water Temperature:
Hot water was measured in both bathrooms. Hot water measured at 113.1 degrees Fahrenheit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
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: IKSHA HOMES/MAGNOLIA
FACILITY NUMBER: 306006461
VISIT DATE: 07/01/2024
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Client & Staff Files:
The Client and Staff Records will be kept locked in the office

Reading Material, Games, Equipment & Materials:
Arts and craft, tablet, and board games are stored in the dining room. There is a large screen TV mounted in the living room.

Fire clearance:
Fire Clearance approved by Anaheim Fire Department Inspector Adam Graef on December 7, 2023.

Component III:
Component three completed with the applicants at the end of the facility tour.

Facility is ready to be licensed. LPA will submit notification to CAB (Central Applications Bureau) in Sacramento for final review prior to license being issued. Applicant was informed today that the final approval will be processed by CAB in Sacramento.

Exit interview was conducted and a copy of this report was left with the applicants.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC809 (FAS) - (06/04)
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