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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006573
Report Date: 10/28/2024
Date Signed: 10/28/2024 11:22:30 AM

Document Has Been Signed on 10/28/2024 11:22 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:ACCESS KARE ONE LLCFACILITY NUMBER:
306006573
ADMINISTRATOR/
DIRECTOR:		PALOMINO, LAURAFACILITY TYPE:
735
ADDRESS:15321 DOGWOOD STTELEPHONE:
(818) 384-9331
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY: 4CENSUS: 0DATE:
10/28/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Kevin ClarkTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Joseph Alejandre conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA met with Applicant Kevin Clark.

An initial application to operate an Adult Residential Facility (ARF) was submitted to CCL on May 7, 2024. The facility is to have a capacity of 4 ambulatory clients. LPAs observed the following. This is a new facility and there are no clients. The facility phone number is .714-248-9882.

Structure:
The facility is a two-story house with 4 bedrooms, 3 bathrooms, living room, dining room, family room, kitchen, office and an attached 2 car garage. There is a large storage shed in the backyard. The backyard has no bodies of water. Both exit gates on each side of the house are operational. The shed is kept locked and used for storage.

Air/Heating:
Central air/heating system installed with a central panel to control entire house.

Client Bedrooms:
There are 4 client Bedrooms, all client bedrooms are 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 garage. The first aid kit has all the required elements. Medications will be stored in the hall closet.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: ACCESS KARE ONE LLC
FACILITY NUMBER: 306006573
VISIT DATE: 10/28/2024
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Bathrooms:
All 3 bathrooms have working showers and toilets. All bathrooms are clean and operational.

Linens & Hygiene Supplies:
Adequate supply of linen stored in the hallway cabinets upstairs.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review. The 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:
LPA observed a 3 day supply of emergency food and water in the garage.

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors/carbon monoxide detectors tested operational. LPA observed the Fire Extinguishers in the kitchen is fully charged

Appliances:
There is a 5 burner gas stove-top which lights unassisted, 2 ovens, microwave oven, a refrigerator and a dishwasher 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 kitchen closet.

Water Temperature:
Hot water was measured in all bathrooms. Hot water measured at 110.9 to 112.1 degrees Fahrenheit.

Client & Staff Files:
The Client and Staff Records will be kept locked in the hall closet
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
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: ACCESS KARE ONE LLC
FACILITY NUMBER: 306006573
VISIT DATE: 10/28/2024
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Reading Material, Games, Equipment & Materials:
Games and puzzles are stored in the living room. There is a large screen TV in the living room and family room.

Fire clearance:
Fire Clearance approved by Orange County Fire Authority Inspector Kevin Chaney on July 15, 2024.

Component III:
Component three was waived because the applicant is the Licensee/Administrator of other licensed facilities.

Facility is ready to be licensed.

Applicant was informed today that the final approval will be processed by CAB (Cental Application Bureau) in Sacramento.

Exit interview was conducted and a copy of this report was left with the applicant.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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