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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006585
Report Date: 01/13/2025
Date Signed: 01/13/2025 04:10:27 PM

Document Has Been Signed on 01/13/2025 04:10 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:STORYLINE MHFACILITY NUMBER:
306006585
ADMINISTRATOR/
DIRECTOR:		ALEXANDER, DAVIDFACILITY TYPE:
772
ADDRESS:31961 CALLE REYNALDATELEPHONE:
(949) 214-9307
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY: 6CENSUS: 0DATE:
01/13/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:David Alexander, Stephanie JonesTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
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Facility phone number is 949-503-2479.
Licensing Program Analyst (LPA) Joseph Alejandre an announced visit to the facility to conduct the pre-licensing inspection. LPA met with Applicants David Alexander and Stephanie Jones. An initial application to operate a Social Rehabilitation Facility (SRF) was submitted to CCL on April 30, 2024. The facility is to have a capacity of 6 ambulatory clients. LPAs observed the following. This is a new facility and there are no clients. The facility phone number is 949-503-1237.

Structure:
The facility is a story house with two separate living areas. Side 1 (the East side) has a living room, kitchen, dining room, bedroom, bathroom, office and upstairs a group room (activity) with 1 bathroom. Side 2 (the West side) has a living room, kitchen, med office, dining room, bedroom, bathroom, sitting room and upstairs, a master bedroom with a bathroom. There is a two car garage that can only be entered from the outside of the house.

Air/Heating:
Central air/heating system installed with a central panel on each side to control the temperature.

Client Bedrooms:
There are a total 3 client bedrooms. One on the East side (side 1) and 2 on the West side (side 2). All bedrooms are shared. 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:
There is first aid kit and the first aid manual in the dining room on each side of the house. The first aid kits have all the required elements. Medications will be stored in the med office and kept in a locked.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2025
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: STORYLINE MH
FACILITY NUMBER: 306006585
VISIT DATE: 01/13/2025
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Bathrooms:
All 5 bathrooms have working showers and toilets. All bathrooms are clean and operational.

Linens & Hygiene Supplies:
Adequate supply of linen stored in hall closet.

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. LPA observed an emergency evacuation chair at the top of both stairways.

Food Service:
LPA observed a 3 day supply of emergency food and water.

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors/carbon monoxide detectors tested operational. All 4 Fire Extinguishers are fully charged and mounted on the wall.

Appliances:
There is a 4 burner gas stove on each side of the house. Both gas stoves light unassisted, 2 microwave ovens, two refrigerators and two dishwashers. The washer and dryer are on the second floor on the West side and on the East side they are on the patio. All appliances are clean and operational.

Toxins:
The cleaning supplies are kept locked in the garage.

Water Temperature:
Hot water was measured in all bathrooms. Hot water measured at 107.1 to 117.2 degrees Fahrenheit.

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

DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
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: STORYLINE MH
FACILITY NUMBER: 306006585
VISIT DATE: 01/13/2025
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Reading Material, Games, Equipment & Materials:
Games and puzzles are stored in the living room on the West side.

Fire clearance:
Fire Clearance approved by Orange County Fire Authority Inspector Andrew Miller on July 1, 2024.

Component III:
Component three completed with applicant.

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: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
LIC809 (FAS) - (06/04)
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