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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006496
Report Date: 05/30/2024
Date Signed: 05/30/2024 12:25:50 PM


Document Has Been Signed on 05/30/2024 12:25 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:
05/30/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Administrator Maria Teresa MisaTIME COMPLETED:
12:45 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 made an announced inspection visit to follow up on corrections identified during Pre Licensing visit on 05/21/2024. LPA identified themselves and discussed the purpose of the visit with Licensee Maria Teresa Misa. An initial application to operate a Residential Facility Care for the Elderly was submitted to CCL on 1/29/2024. There are 0 residents in care during today's visit. LPA observed the following:

At 11:35 AM LPA toured the facility and observed the following:
· Let Us Know Poster is proper size 20x26 and posted near entrance
· Facility has proper First Aid Handbook, Tweezers and Thermometer
· Facility has obtained emergency water supply
· Facility closed off passageway door from common area restroom and Caregiver room
· Facility closed off door between two resident rooms
· Facility has internet access device for residents use
· Facility has operable land line phone.

LPA conducted Component III during visit with Administrator Misa. Noted items from visit on 05/21/2024 have been addressed. The facility is ready to be licensed.


Exit interview conducted with Administrator 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: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024
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 1