306006606-9-13-2024-22-AS-EKIM-D93PDR-20240913111359

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006606
Report Date: 09/13/2024
Date Signed: 09/13/2024 11:15:16 AM

Document Has Been Signed on 09/13/2024 11:15 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:	B & B HOME CARE		FACILITY NUMBER:	306006606
ADMINISTRATOR:	DEL CASTILLO, LIBERTY		FACILITY TYPE:	740
ADDRESS:	3173 W POLK AVENUE		TELEPHONE:	(714) 886-2280
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY:	6	CENSUS: 5	DATE:	09/13/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Liberty Del Castillo		TIME COMPLETED:	11:30 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	On September 13, 2024, at 8:00am, Licensing Program Analyst (LPA) Edward Kim conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA Kim met with Applicant Liberty Del Castillo and toured the facility. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to CCL on July 25, 2024. The facility is to have a capacity of six (6), of which one is ambulatory, four (4) can be nonambulatory and of which one (1) may be bedridden. Applicant has requested a hospice waiver for six (6) residents. Facility phone number (714-886-2280). LPA Kim observed the following. Structure: The facility is a one-story house with an attached 2 car garage with six (6) bedrooms, three (3) bathrooms, dining room, a kitchen, and a living room. There are four (4) exits: one exit door in the living room, one in the front door, one in bedroom #4 which is the bedridden room, and one in bedroom #6. Air/Heating: Central air/heating system installed with a central panel to control entire house located in the hallway. Resident Bedrooms: There are four (4) Resident Bedrooms: Bedroom #1, Bedroom #4, Bedroom #5, and Bedroom #6. The bedrooms are spacious and will easily accommodate the residents' belongings. All resident rooms had the required furnishings. Staff Bedrooms: There are two (2) Staff Bedrooms. Bedroom #2 and Bedroom #3 are staff bedrooms. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

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: B & B HOME CARE	FACILITY NUMBER: 306006606
	VISIT DATE: 09/13/2024

NARRATIVE

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Bathrooms:
All bathrooms have a working toilet, wash basin and shower. All bathrooms are clean. Shower mats were in all three bathrooms. Hot water was measured in all bathrooms. Hot water measured between 113.5 degrees Fahrenheit to 120.0 degrees Fahrenheit.

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

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed and posted in the entrance hallway. Menus posted and available next to the emergency information in entrance hallway..

Food Service:
There are residents living in the facility at this time. There is a 2-day perishable food. There is 7-day non-perishable food supply on hand. The emergency food, emergency water, and emergency supplies are stored in the garage.

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors/carbon monoxide detectors are hardwired and tested operational. There is a fire extinguishers mounted on the wall in the kitchen. The fire extinguisher is fully charged and was serviced on December 19, 2023.

Toxins:
All cleaning supplies and chemicals are kept in the garage.

Outdoor/Yard:
There is a small fountain next to the exit by bedroom#6. There is an outdoor furniture with an umbrella to cover the table and chairs. All outdoor gates are self-closing and self-latching.

Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

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: B & B HOME CARE	FACILITY NUMBER: 306006606
	VISIT DATE: 09/13/2024

NARRATIVE

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Medications, First-Aid Kit & Book:
The first aid kit and all medications are stored in medical cabinet in the resident hallway across from Bedroom#1. The first aid kit has all the required elements. The cabinets are kept locked.

Resident & Staff Files:
The Resident and Staff Records will be kept locked in filing cabinets located in the living room.

Reading Material, Games, Equipment & Materials:
Books and board games are stored in the living room. There is a large screen TV in the living room.

Appliances:
There is one five (5) gas burner stove which lights unassisted, oven, microwave oven, a refrigerator in the kitchen, two (2) refrigerators in the garage, dishwasher, washer, and dryer. All appliances are clean and operational.

Fire clearance:
Fire Clearance approved by Anaheim Fire Department on August 6, 2024.

Component III:
Component three waived during visit. Applicant is Licensee/Administrator of the facility changing from Sole Proprietor to LLC.

The pre-licensing visit and Component III Orientation are now complete. It appears this facility meets the requirements for licensure. LPA Kim will forward this report to the Centralized Applications Bureau for review. The license will be granted upon completion of a final review and approval from the Centralized Applications Bureau.

Exit interview was conducted and a copy of this report was left with Applicant Liberty Del Castillo.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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