306006529-8-13-2024-22-AS-JALE-D84V6C-20240813160918

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006529
Report Date: 08/13/2024
Date Signed: 08/13/2024 04:09:41 PM

Document Has Been Signed on 08/13/2024 04:09 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:	GOLDEN HEARTS ELDERLY CARE 2		FACILITY NUMBER:	306006529
ADMINISTRATOR:	ELAHI, NARGIS		FACILITY TYPE:	740
ADDRESS:	25231 ROMERA PLACE		TELEPHONE:	(949) 716-0016
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 0	DATE:	08/13/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Nargis Elahi		TIME COMPLETED:	04:30 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) Joseph Alejandre conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA met with Applicants Himal Thebe and Smriti Thebe and toured the facility. An initial application to operate an Adult Residential Facility (ARF) was submitted to CCL on March 4, 2024. The facility is to have a capacity of 6 non-ambulatory resident of which one can be bedridden. Resident room number one (1) is the only room approved for a bedridden resident. LPA observed the following. This is a change of ownership application with clients in care. Structure: The facility is a single story house with an attached 2 car garage with 7 bedrooms (room 4 is for staff), 2 bathrooms and a great room. Air/Heating: Central air/heating system installed with a central panel to control entire house. The air conditioning was operating during the visit. Resident Bedrooms: There are 6 resident Bedrooms and each bedroom is private. The bedrooms are spacious and will easily accommodate the clients' belongings. All client rooms had the required furnishings and linens. Medications, First-Aid Kit & Book: The first aid kit and the first aid manual are stored in the kitchen. The first aid kit has all the required elements. Medications will be stored in the kitchen cabinet and kept locked.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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: GOLDEN HEARTS ELDERLY CARE 2	FACILITY NUMBER: 306006529
	VISIT DATE: 08/13/2024

NARRATIVE

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Bathrooms:
Both bathrooms have a working toilet, wash basin and walk in shower. Both bathrooms are clean and operational.

Linens & Hygiene Supplies:
Adequate supply of linen stored in hall closet. Extra hygiene supplies are stored in the garage.

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 posted and available. Menus prepared one week prior and listed for food served for one week.

Food Service:
There is no food at the facility.

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors/carbon monoxide detectors tested operational. The fire extinguishers (2) are new and fully charged but they are not mounted.

Appliances:
There is a 5 burner gas stove which includes an oven, microwave oven and refrigerator in the kitchen. The washer and dryer are in the garage. All appliances are clean and operational.

Toxins:
The cleaning supplies are kept locked in the garage.

Water Temperature:
Hot water was measured in both bathrooms. Hot water measured at 122.5 to 123.0 degrees Fahrenheit.

Client & Staff Files:
The Client and Staff Records will be kept locked in the kitchen cabinet.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GOLDEN HEARTS ELDERLY CARE 2	FACILITY NUMBER: 306006529
	VISIT DATE: 08/13/2024

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Reading Material, Games, Equipment & Materials:
Arts and craft, and board games are stored in the great room. There is a large screen TV mounted in the great room. At this time the facility does not have internet access.

Fire clearance:
Fire Clearance approved by Anaheim Fire Department Inspector Ruben Gomez on April 2, 2024.

Component III:
Component three waived. Applicant is a Licensee/Administrator of a Licensed Facility.

Facility is not ready to be licensed. The following items must be completed prior to the facility being licensed.

LPA observed the front yard patio is under construction and not yet completed. There is no shaded outdoor seating area for residents. The front yard covered patio must be completed and have seating for residents including table and chairs for outdoor use.
LPA observed concrete blocks, tools and boxes stored on the side of the house by the exit gate. The side of the house must be cleared of all items except the garbage cans.
The hot water must be adjusted to measure between 105.0 to 120.0 degrees Fahrenheit.
The fence on the side of the house is being held up by pieces of wood that are not part of the original fence. The side fence must be repaired or replaced so it can stand on its own.
LPA observed numerous paver bricks in the backyard stacked on the ground. The paver bricks must be removed or installed. The PUB 475 poster must be 20 by 26 inches and posted in the main entry way.
The fire extinguishers must be mounted in the kitchen and hallway.
Facility must have a phone number.

Applicant was informed the must contact the LPA to schedule the second pre-licensing visit.

Applicant was informed today that the final approval will be processed by CAB in Sacramento after the pre-licensing has been successfully completed.
Exit interview was conducted and a copy of this report was left with the applicant.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC809 (FAS) - (06/04)

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