306006562-10-17-2024-22-AS-KSGH-DA5NMY-20241017103555

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006562
Report Date: 10/17/2024
Date Signed: 10/17/2024 10:36:59 AM

Document Has Been Signed on 10/17/2024 10:36 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:	LEGENDS HEALTHCARE		FACILITY NUMBER:	306006562
ADMINISTRATOR/ DIRECTOR:	STICKEL, JEFF		FACILITY TYPE:	772
ADDRESS:	25226 DERBY CIRCLE		TELEPHONE:	(925) 321-7655
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY: 6		CENSUS: 0	DATE:	10/17/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Jeff Stickel, Administrator		TIME VISIT/ INSPECTION COMPLETED:	10:50 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) Kevin Saborit-Guasch and Samer Haddadin conducted an announced visit to the facility in order to conduct a pre-licensing evaluation. An initial application to operate a Social Rehabilitation Facility was submitted to Community Care Licensing on April 17, 2024 for a capacity of six (6) capacity ambulatory clients. Structure: The facility is a two story house with an attached garage with 4 client bedrooms, 3 full bathrooms, a living room, a therapy office, additional offices in the garage and on the second floor as well as a kitchen. The client’s bedrooms are spacious, furnished with individual storage space. There is a large back yard with an exit walkway on each side of the house with covered seating for the clients. Garage will be used as an office, laundry area as well as for storage. Client Residents: Bedrooms will accommodate 6 clients with 2 private bedrooms and 2 shared bedrooms accommodating two clients. Bedrooms Staff: No bedroom designated for awake-staff. Bathrooms: All bathrooms have a working toilet, wash basin, walk in shower or bathtub. CONTINUED ON FORM LIC809-C

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

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: LEGENDS HEALTHCARE	FACILITY NUMBER: 306006562
	VISIT DATE: 10/17/2024

NARRATIVE

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CONTINUED FROM FORM LIC809
Linens & Hygiene Supplies:
Adequate supply of linen stored in hallway space in the 2nd floor as well as first level office and 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. No evacuation chair present at the time of the visit, a chair was ordered for delivery in the following week.

Food Service:
Adequate supply of 7-day non-perishable and 2-day perishables will be stored in the kitchen.

Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired, were tested and found operational.

Appliances:
gas burner stove, one oven, 3 refrigerators, dishwasher, microwave, washer, and dryer are clean and noted to be operational.

Toxins:
All and any toxic chemicals, cleaning solutions and disinfectants inaccessible to clients are stored in garage.

Water Temperature:
Water temperature measured over 125F in bathrooms on the first and second level.

Medications, First-Aid Kit & Book:
In lock stage cabinet in office space. First aid manual observed. Three first aid kits located throughout the facility.

Client & Staff Files:
Records will be kept in locked cabinet space located in the therapy office.
CONTINUED ON FORM LIC809-C

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

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: LEGENDS HEALTHCARE	FACILITY NUMBER: 306006562
	VISIT DATE: 10/17/2024

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CONTINUED FROM FORM LIC809
Fire clearance:
Approved by the Orange County Fire Authority on May 2nd, 2024.

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

Due to the absence of an evacuation chair for the second floor as well as water temperatures noted to be in excess of the mandated range, a follow-up visit will be conducted on October 23, 2024.

An exit interview was conducted and a copy of this report was left with the applicant.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

LIC809 (FAS) - (06/04)

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