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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006529
Report Date: 09/05/2024
Date Signed: 09/05/2024 02:25:58 PM


Document Has Been Signed on 09/05/2024 02:25 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:GOLDEN HEARTS ELDERLY CARE 2FACILITY NUMBER:
306006529
ADMINISTRATOR:ELAHI, NARGISFACILITY TYPE:
740
ADDRESS:25231 ROMERA PLACETELEPHONE:
(949) 716-0016
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 0DATE:
09/05/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Nargis ElahiTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an announced visit to conduct the second pre-licensing visit. LPA met with applicant Nargis Elahi. LPA and applicant toured the facility. LPA observed the following items have been corrected. LPA observed the fence on the side of the house has been replaced with a new fence that is not tilted or falling. LPA measured the hot water in both bathrooms and it measured 105.2 degrees Fahrenheit. LPA observed the PUB 475 poster is posted in the main entry of the facility and meets all the regulation requirements. LPA observed the front yard patio has been completed and has tables and chairs for outdoor use. LPA observed all the items on the side of the house have been cleared. LPA observed all the loose concrete blocks have been removed from the backyard and pavers (bricks) have been installed in the backyard. The facility now has a phone number. The facility phone number 949-795-2082. The fire extinguisher in the kitchen and the hallway are fully charged and mounted. All of the items noted on the first pre-licensing inspection have been corrected (See LIC 809 dated (August 13, 2024).

Component III waived applicant is a Licensee/Administrator of a Licensed Facility.

The facility is ready to be licensed.

Applicant was informed today that the final approval will be processed by CAB (Cental Applications Bureau) in Sacramento. Exit interview was conducted and a copy of this report was provided to the applicant..
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
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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