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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006554
Report Date: 08/27/2024
Date Signed: 08/27/2024 04:16:25 PM


Document Has Been Signed on 08/27/2024 04:16 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:LEGACY SENIOR LIVING 2FACILITY NUMBER:
306006554
ADMINISTRATOR:TRAN, HONGLANFACILITY TYPE:
740
ADDRESS:19142 STINGRAY LANETELEPHONE:
(714) 249-0176
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY:6CENSUS: 0DATE:
08/27/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Thi Nhu Mai DoTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Lydia Martinez made an announced visit to the facility to conduct a Pre-Licensing inspection. LPA identified herself and discussed the purpose of the visit with Applicant Thi Nhu Mai Do. Consultant Ban Nguyen was present as well. An initial application to operate a Residential Care Facility for the Elderly was submitted to Community Care Licensing on 04/18/2024 for a capacity of four non-Ambulatory, one Ambulatory, and one bedridden resident. Upon entry, facility appears clean, safe and sanitary. Facility has all required postings at entrance.

LPA Martinez along with Applicant Do and Ban toured the facility and observed the following:

Structure: Facility is a two story, 6 bedroom, 4 bathroom house with an attached garage. The outside exit gates are closed and unlocked. Garage: Two car garage with a small built room with washer/dryer; will be used as laundry room and storage only. Living Room/Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: Rooms will be two private and two shared. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Staff: Facility will have live-in staff and will occupy upstairs bedrooms. Linens & Hygiene Supplies: Facility has ample bedding and towels in supply. Bathrooms: All resident bathrooms have a working toilet/wash basin as well as grab bars and non-skid surface in the shower. Emergency Phone Numbers and Exit Plan: Posted in the entrance of the facility. Food Service: Applicant understands to have a supply of 2 day perishables as well as 7 day non-perishables at all times when residents present. Smoke Detectors: Smoke detectors are hard wired; carbon monoxide detectors were operational. Fire extinguisher is fully charged and mounted. The three non-Ambulatory bedrooms have self closing Fire doors. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational.

(cont on LIC809C)
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 705-6004
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024
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: LEGACY SENIOR LIVING 2
FACILITY NUMBER: 306006554
VISIT DATE: 08/27/2024
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Toxins/Sharps: Facility has secured areas for toxins and sharps. Water Temperature: Hot water temperature is within regulatory requirements. Emergency Supplies: LPA observed ample emergency water as well as a posted Emergency Disaster Plan. Medications, First-Aid Kit & Book: First aid kit observed contained all required items including tweezers, scissors and thermometer. LPA observed a First Aid Manual. There is are locked kitchen cabinet for medication. Facility to use a medication administration record. Resident & Staff File: Records are to be stored and secured. Reading Material, Games, and Equipment: LPA observed a board games for residents use. Backyard: LPA observed a clean backyard with ample shaded seating for residents and visitors. Fire Clearance: Approved for four non-Ambulatory and one bedridden resident on 05/08/2024.

Component III was completed with Applicant during today’s inspection. Applicant will obtain liability insurance once the application is approved.

Facility appears to be in compliance and ready to be licensed. License will be granted upon completion of a final review and approval from the Application Specialist.

An exit interview was conducted and a copy of this report will be sent to the email on file
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 705-6004
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC809 (FAS) - (06/04)
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