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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006496
Report Date: 05/21/2024
Date Signed: 05/21/2024 04:26:35 PM


Document Has Been Signed on 05/21/2024 04:26 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:HOME AT CASCADE LANE, INC.FACILITY NUMBER:
306006496
ADMINISTRATOR:MISA, MARIA TERESA C.FACILITY TYPE:
740
ADDRESS:15311 CASCADE LANETELEPHONE:
(714) 515-0459
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 0DATE:
05/21/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Licensee Maria Teresa MisaTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Jenifer Tirre visited this facility for the purpose of conducting a Pre-Licensing evaluation. Facility is a single story residential home. LPA along with Administrator/Licensee Maria Teresa Misa toured facility at 1:05PM and observed the following:

Structure: Facility is a one story, 8 bedroom (6 Residents bedrooms and 2 live in staff bedroom) 3 bathroom house with attached garage and a blue exterior. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: All Residents bedrooms meet Licensing requirements. Bathrooms: All resident 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 and towels. Emergency Phone Numbers and Exit Plan: Facility has Emergency Plan posted on wall. Food Service: Facility has 2 day perishables as well as 7 day non-perishables in the pantry/ refrigerator, as well as emergency food supply. Smoke Detectors: Smoke detectors/ carbon monoxide detector are centrally wired and were tested operational. Facility has 3 Fire extinguishers, mounted and fully charged. Facility has audible alarms on all sliding/exit doors. Appliances: Gas Stove, microwave and refrigerator are operational. Toxins: LPA observed toxins secured in laundry storage area.. Water Temperature: Tested and recorded at 113.1 degrees F. in facility bathrooms. Reading Material Games, and Equipment:
facility does exercises, puzzles and games. Medications, First-Aid Kit & Book: Facility has first aid kit present at the facility. 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 as required. LPA observed shaded outdoor seating. Fire Clearance: Approved for 5 non-ambulatory residents and 1 bedridden on 04/15/2024.

CONTINUED ON 809C

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HOME AT CASCADE LANE, INC.
FACILITY NUMBER: 306006496
VISIT DATE: 05/21/2024

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Licensee to address the following corrections by 5/30/24:
  • Let Us Know Poster is not regulation size, please have proper size poster 20x26 posted near entrance
  • Facility needs First Aid Handbook, Tweezers and Thermometer
  • Facility needs emergency water supply
  • Facility to close off passageway door from common area restroom and Caregiver room
  • Facility to close off door between two resident rooms
  • Facility to provide internet access device for residents
  • Facility to have operable land line phone.

The facility is not ready to be licensed. Licensee to contact LPA when corrections are complete.

Component III will be conducted at follow up visit.

An exit interview was conducted with Licensee and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC809 (FAS) - (06/04)
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