306006519-5-1-2024-22-AS-JHAY-D4UPJN-20240501112148

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006519
Report Date: 05/01/2024
Date Signed: 05/01/2024 11:22:00 AM

Document Has Been Signed on 05/01/2024 11:22 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:	B&C SENIOR LIVING		FACILITY NUMBER:	306006519
ADMINISTRATOR:	EUGENIO, JOHN JASON		FACILITY TYPE:	740
ADDRESS:	1354 N FERNDALE ST.		TELEPHONE:	(714) 488-8413
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY:	6	CENSUS: 0	DATE:	05/01/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Brian Estorba John Jason Eugenio		TIME COMPLETED:	11:30 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 Analysts (LPAs) Jerome Haley and Edward Kim conducted an announced visit to the facility to conduct the pre-licensing inspection. LPAs met with Applicant Brian Estorba and John Jason Eugenio and toured the facility. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to CCL on December 18, 2023. The facility is to have a capacity of 6, of which 5 can be nonambulatory and 1 bedridden. Facility phone number 657.214.2818. LPAs observed the following. Structure: The facility is a one story house with a 2 car garage with 5 bedrooms (1 is for staff), 3 bathrooms, dining room/living room, and a kitchen. There are 4 exits, one exit door in the kitchen, one in the hallway outside of bedroom 7, the front door and the exit in bedroom 5 which is approved for 1 bedridden resident. Air/Heating: Central air/heating system installed with a central panel to control entire house. Resident Bedrooms: There are 4 Resident Bedrooms. 2 Resident bedrooms are share and 2 bedrooms are private. The bedrooms are spacious and will easily accommodate the residents' belongings. Bedrooms Staff: Bedroom 2 is designated as the staff bedroom. 1 of 3 Continued on LIC809C

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

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: B&C SENIOR LIVING	FACILITY NUMBER: 306006519
	VISIT DATE: 05/01/2024

NARRATIVE

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Bathrooms:
All bathrooms have a working toilet, wash basin and shower, except for bathroom 3 which has no shower. All bathrooms are clean.

Linens & Hygiene Supplies:
An adequate supply of linen was observed.

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 will be posted and available.

Food Service:
There are no residents living in the facility at this time.

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors/carbon monoxide detectors are hardwired and tested operational. There is fire extinguisher mounted in the kitchen.

Appliances:
There is one 4 gas burner and griddle stove which lights unassisted, 1 oven, a refrigerator, dishwasher, washer, and dryer. All appliances are clean and operational.

Toxins:
All cleaning supplies and chemicals are kept in two areas: kitchen cleaning supplies locked under the kitchen sink and all extra cleaning supplies are locked in the garage..

Water Temperature:
Hot water was measured in all bathrooms. Hot water measured between degrees Fahrenheit. Hot water temperature was measured at between 143 - 146.8 degrees F.

2 of 3 Continued on LIC809C

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

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

FACILITY NAME: B&C SENIOR LIVING	FACILITY NUMBER: 306006519
	VISIT DATE: 05/01/2024

NARRATIVE

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Medications, First-Aid Kit & Book:
The first aid kit and the first aid manual will be stored in the locked closet in the hallway with the staff and resident files. Medications will be stored in a locked kitchen cabinet above the counter near the fire extinguisher.

Resident & Staff Files:
The Resident and Staff Records will be kept locked in the closet next to staff room (bedroom #2).

Reading Material, Games, Equipment & Materials:
None.

Fire clearance:
Fire Clearance approved by Anaheim Fire Department on March 26, 2024.

LPAs observed the following items that must be corrected: 1) fire extinguisher did not have a service date tag, 2) backyard needs to be in good repair by removing clutter (bricks, pipes, and other items), 3) left side near the gate has several planks of wood and a wheelbarrow that needs to be cleared, 4) the garage needs the exposed wires of the sprinkler system to be covered, 5) outdoor security light needs bulbs, 6) staff bathroom toilet needs maintenance due to overflow and leaks, 7) non-slip mats in the bathrooms, 8) grab bars in both restrooms, 9) the wires from Satellite dish need to be removed or properly secured, and 10) outdoor gates need to be self-latching and self-closing.

The applicant plans on making the necessary corrections and contacting LPA Haley to schedule a follow up pre-licensing inspection.

Exit interview was conducted and a copy of this report was provided. .

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SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC809 (FAS) - (06/04)

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