306006530-9-16-2024-22-AS-JHAY-D96P4D-20240916105857

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006530
Report Date: 09/16/2024
Date Signed: 09/16/2024 10:59:05 AM

Document Has Been Signed on 09/16/2024 10:59 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:	FAMILY TIES SENIOR LIVING		FACILITY NUMBER:	306006530
ADMINISTRATOR:	RAJPOOT, FAISAL		FACILITY TYPE:	740
ADDRESS:	6096 SHERIDAN WAY		TELEPHONE:	(949) 290-1826
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY:	6	CENSUS: 0	DATE:	09/16/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Faisal Rajpoot & Kamil Rajpoot		TIME COMPLETED:	11:15 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 made an announced visit for the purpose of conducting a pre-licensing evaluation. LPA Haley was greeted and granted entry by applicants Fasial and Kamil Rajpoot. An initial application to operate a Residential Care Facility for Elderly, with a capacity of 5 non-ambulatory residents and 1 bedridden resident. Fire clearance: Orange County Fire Authority granted the Fire Clearance July 11, 2024 Structure: The facility is a single level structure, with an attached garage. There’s a total of four bedrooms, 3 of which are for residents, living room space, and one dining room. Bedrooms Residents: All bedrooms have the required furnishings: bed, lamp, chair, and storage space. Bathrooms: Bathrooms are equipped with a working toilet, wash basin, and walk in shower. Hot Water Temperature in Bathroom #1 was measured at 108.8 degrees Fahrenheit and 107.9 degrees Fahrenheit in bathroom #2. Kitchen: The gas stove was operational, and all 5 burners were in good working order. Knives and sharp objects will be locked in a cabinet above the stove. Food Service: A sample menu was observed on the refrigerator. An emergency supply of non-perishable food items is stored in the garage. Garage: There’s a washer and dryer in the locked garage. Hazardous cleaning chemicals, hygiene items, emergency supplies, are stored in the garage. The ceiling in the garage needs to be completed to cover exposed studs and a couple exposed wires before being licensed. There's an extra refrigerator that will be used to store an additional food supply. Resident & Staff Files: Resident files and staff files will be stored in a locked filing cabinet that will be stored in the garage. Continued on LIC809C

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

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: FAMILY TIES SENIOR LIVING	FACILITY NUMBER: 306006530
	VISIT DATE: 09/16/2024

NARRATIVE

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Medications, First-Aid Kit: Medication and first aid kit will be stored in the kitchen in a locked cabinet above the counter top.

Linens & Hygiene Supplies: Adequate supply of linen was stored in a cabinet in the hallway. Hygiene supplies will be stored in the cabinets in the hallway and extra hygiene supplies will be stored in the garage. All laundry detergents and hazardous cleaning items will be stored in the locked garage. Toxins: All toxic chemicals, cleaning solutions, laundry detergents and disinfectants are inaccessible to residents are stored in the locked garage.

Backyard/Exterior:
There is a large backyard with a self-closing and self-latching exit gate. A shaded patio area with a table and chairs was observed. All walkways were clear and free of obstruction.
Bodies of Water: No bodies of water were observed.

Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors are hardwired and tested operational. Two additional carbon monoxide detectors were observed mounted on the walls in the facility.

Emergency Phone Numbers, House Rules, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan, a list of emergency phone numbers, house rules on the facility postings board in the hallway, and a sample menu posted in the kitchen.

Fire Extinguisher: Observed full charged and mounted in the kitchen.

During the visit, the following was observed which must be corrected. 1. Ceiling in the garage needs to be completed. 2. Cover exposed wires in the garage. 3. Fireplace screen for the fireplace in the living room. 4. Additional activities and/or games available for the residents.

Component III: Will be waived as the facility is not ready to be licensed at this time.

An exit interview was conducted, and a copy of this report was provided to applicants Faisal Rajpoot and Kamil Rajpoot.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC809 (FAS) - (06/04)

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