306006580-9-19-2024-22-AS-JCHO-D99L47-20240919082505

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006580
Report Date: 09/19/2024
Date Signed: 09/19/2024 08:25:13 AM

Document Has Been Signed on 09/19/2024 08:25 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:	CARE ACHILLES		FACILITY NUMBER:	306006580
ADMINISTRATOR:	GABRIEL, JEHLA ROSE		FACILITY TYPE:	740
ADDRESS:	598 PIERPONT DR		TELEPHONE:	(424) 270-4452
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 0	DATE:	09/19/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	07:00 AM
MET WITH:	Jehla Rose Gabriel- Applicant		TIME COMPLETED:	08:50 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 Analyst (LPA) Jessica Cho arrived announced for the purpose of conducting a Pre-Licensing visit using the Care Inspection Tool. LPA conducted the visit with Applicant Jehla Rose Gabriel. An initial application to operate a Residential Care Facility for the Elderly (RCFE), age range 60 and over, for (0) ambulatory, (5) non-ambulatory, and (1) bedridden residents was received by the Department of Social Services on May 20, 2024.

LPA toured the interior and exterior portion of the facility and observed the following accompanied by the Applicant Jehla Rose Gabriel.

Structure:

The facility is a two story property in a residential neighborhood. The first floor will be occupied by residents and is comprised of six resident bedrooms and four resident full bathrooms. There is a living room, dining area, kitchen, laundry room, an attached two car garage, and a backyard. The loft is on the second floor with a full bathroom which will be occupied by the staff. The backyard has one exit gate on one side of the property. There is a shaded seating area. LPA did not observe any obstacles or hazards in the backyard.

Signal System:
The facility utilizes a signal system where staff is alerted from a central location located in the kitchen.

Bedrooms:
The resident bedrooms had all required components, are spacious, and easily accommodates the residents’ furnishings.

Bathrooms:
Bathrooms were not clean and operational. Grab bars were secure and bath slip mats were in place.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

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: CARE ACHILLES	FACILITY NUMBER: 306006580
	VISIT DATE: 09/19/2024

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
26
27
28
29
30
31
32

Linens and Hygiene Supplies:
Clean linens and hygiene supplies were observed to be fully stocked.

Appliances:
Stove burners, microwaves, washer, and dryer were inspected and operating.

Resident and Staff Files:
Resident and staff records will be maintained on site.

Reading Material, Games, Equipment, & Materials:
The facility maintains reading material and games in the facility under the TV console.

Emergency Phone Numbers/Exit Plan:
Posted in the entry way area and available for review.

Postings:
The See Something, Say Something (PUB475) and the Ombudsman Posters were posted in the entry area of the facility. The Rights of the Resident Councils, Resident's Rights, Theft & Loss Policy, Activity Schedule, and Admission Agreement were posted and is accessible in a folder in the entry way.

Food Service and Menu:
Supply of seven day non-perishable and two day perishables were observed. The sample menu was available for review. The emergency food/water supply was available.

Smoke and Carbon Monoxide Detectors:
The dual functioning smoke detectors, carbon monoxide alert systems, and auditory devices were tested and found to be operational.

Fire Extinguishers:
Four fire extinguishers were mounted, fully charged, and serviced on June 3, 2024.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

Page: 2 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: CARE ACHILLES	FACILITY NUMBER: 306006580
	VISIT DATE: 09/19/2024

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
26
27
28
29
30
31
32

Fire Clearance:
Approved on July 2, 2024 for (5) non-ambulatory residents and (1) bedridden resident.

Toxins and Sharps:
Cleaning supplies, toxins, and sharps were secured and inaccessible in a locked closet in the garage.

Water Temperature:
The water temperature in the resident bathrooms measured at 119.1, 116.6, 119.8, and 116.7 degrees Fahrenheit in the resident bathrooms on the first floor.

Medications, First Aid Kit & Manual:
The First Aid Kit was checked and found to be in order including the First Aid Manual.

Component III:
Component III is waived due to the applicant currently operating a licensed facility and having completed Component III previously.

The following items need correction prior to licensure:

To obtain and provide proof of liability insurance coverage.
To replace the flooring of the stairs leading to the loft on the second floor (which was part of the initial plan of the applicant)

Facility does not appear ready for licensure. Any items noted above during today’s visit are to be corrected by September 25, 2024 at 7:00a.m.

An exit interview was conducted with Applicant Jehla Rose Gabriel, and a copy of this report was provided at the end of the visit.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3