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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006526
Report Date: 07/12/2024
Date Signed: 07/12/2024 10:52:15 AM

Document Has Been Signed on 07/12/2024 10:52 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:KAELA'S HOME FOR ELDERLYFACILITY NUMBER:
306006526
ADMINISTRATOR/
DIRECTOR:		DUMALIANG, CZARINE SFACILITY TYPE:
740
ADDRESS:24176 MCOY ROADTELEPHONE:
(310) 308-0925
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 0DATE:
07/12/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Czarina Dumaliang-ApplicantTIME VISIT/
INSPECTION COMPLETED:
11:07 AM
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Licensing Program Analysts (LPA) Alvaro Ramirez, Jr. conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA met with Applicant Czarina Dumaliang and toured the facility.

An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to Community Care Licensing (CCL) on January 17, 2024. The facility is to have a capacity of 6, of which 5 can be nonambulatory and 1 bedridden. Facility phone number 949-446-4085. LPA observed the following.

Structure:
The facility is a one-story house with five resident bedrooms, one staff bedroom, three full size bathrooms, two half bathrooms, a living room, a kitchen, a dining room, and an attached 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 with an exit gate. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard.

Air/Heating:
Central air/heating system installed with a central panel to control entire house.

Resident Bedrooms:
There are five Resident bedrooms. All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets.


CONTINUED ON LIC809-C...
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2024
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: KAELA'S HOME FOR ELDERLY
FACILITY NUMBER: 306006526
VISIT DATE: 07/12/2024
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Bathrooms:
All bathrooms are clean and have working plumbing. Hot water measured between 107.3 and 109.5 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in a closet by the residents' bedroom hallway.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu posted and available. Monthly menu available and posted in the kitchen.

Food Service:
There are no residents living in the facility at this time. There is 7-day non-perishable food supply on hand.

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors/carbon monoxide detectors are hardwired and tested operational. There is a fire extinguisher mounted on the wall by the living room.

Appliances:
There is one, four electric burner stove which lights unassisted, one oven, one microwave, a refrigerator, dishwasher, washer, and dryer. All appliances are clean and operational.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored in the garage and laundry room.

Water Temperature:
Hot water was measured in all bathrooms. Hot water measured between 107.3 and 109.5 degrees Fahrenheit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
LIC809 (FAS) - (06/04)
Page: 2 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: KAELA'S HOME FOR ELDERLY
FACILITY NUMBER: 306006526
VISIT DATE: 07/12/2024
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Medications, First-Aid Kit & Book:
Medications, the first aid kit and the first aid manual will be stored in a locked closet by the residents' bedroom hallway. The first aid kit has all the required elements.

Resident & Staff Files:
The Resident and Staff Records will be kept in a locked closet by the residents' bedroom hallway.

Reading Material, Games, Equipment & Materials:
Arts and craft, board games and light exercise equipment are stored in the living room cabinet. There is one large screen television in the living room.

Fire clearance:
Fire Clearance approved by a fire inspector of Orange County Fire Authority on March 05, 2024. Special conditions noted, "Bedridden client located in Room #3."

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


The applicant has met all pre-licensing requirements. LPA will submit notification to Central Applications Bureau (CAB) 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 applicant.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
LIC809 (FAS) - (06/04)
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