306006507-6-6-2024-22-AS-CGUZ-D5YN4K-20240606100805

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006507
Report Date: 06/06/2024
Date Signed: 06/06/2024 10:09:19 AM

Document Has Been Signed on 06/06/2024 10:09 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	PHAMILY HOME ELDERLY CARE 3		FACILITY NUMBER:	306006507
ADMINISTRATOR:	GARDNER, JEFFREY L.		FACILITY TYPE:	740
ADDRESS:	700 S JANSS ST.		TELEPHONE:	(657) 724-9930
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92805
CAPACITY:	6	CENSUS: 0	DATE:	06/06/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Charles Pham		TIME COMPLETED:	10:25 AM

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) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with Licensee Charles Pham. An application to operate a Residential Care Facility for the Elderly (RCFE) for (6) capacity, (3) ambulatory, (2) non-ambulatory, and (1) bedridden residents was received by CCL on January 29, 2024. Structure: The facility is a one-story house with five bedrooms, three bathrooms, a living room, a kitchen, and attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entranceway. There is a backyard that wraps around to the front yard on one side of the home and an exit gate on the opposite side. There is a shaded seating area in both the front and back yard of the home, and LPA did not observe any obstacles or hazards. Resident Bedrooms All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets. Signal system There is no signal system. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked underneath the kitchen sink and in the garage. Medications, First-Aid Kit & Book: Medication will be stored in a locked closet. First aid kit is stored with the medication. The first aid kit has all the required elements.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PHAMILY HOME ELDERLY CARE 3	FACILITY NUMBER: 306006507
	VISIT DATE: 06/06/2024

NARRATIVE

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Resident & Staff Files:
Records will be kept in a locked file cabinet.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
Fire extinguishers are fully charged.

Reading Material, Games, Equipment & Materials:
The facility has magazines, board games, puzzles, and other recreational materials for resident use stored in the living room and hallway storage.

Fire clearance:
Was approved by a fire inspector of Anaheim Fire Department on March 11, 2024. Special conditions noted, “Bedridden = Bedroom #4. Non-ambulatory = Bedroom #5”

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Bedrooms Staff:
There is no staff bedroom.

Bathrooms:
All bathrooms have working plumbing. Hot water measured between 106.5- and 112.0- degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PHAMILY HOME ELDERLY CARE 3	FACILITY NUMBER: 306006507
	VISIT DATE: 06/06/2024

NARRATIVE

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Emergency Phone Numbers, Exit Plan & Menu:
Posted and available, means of exiting, and emergency phone numbers. Food menu was also posted.

Food Service:
A supply of 2-day perishable and 7-day of non-perishable food was observed and will be maintained on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas burner stove, dishwasher, refrigerator, microwave, washer, and dryer are operational.

Licensee was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted and a copy of this report was provided to Licensee.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

LIC809 (FAS) - (06/04)

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