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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090073
Report Date: 04/11/2024
Date Signed: 04/11/2024 04:31:35 PM


Document Has Been Signed on 04/11/2024 04:31 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:ARROW HOUSE, THEFACILITY NUMBER:
306090073
ADMINISTRATOR:EHSAN EBRAHIMFACILITY TYPE:
730
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:20CENSUS: 5DATE:
04/11/2024
TYPE OF VISIT:Required - 2 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Ehsan EbrahimTIME COMPLETED:
05:00 PM
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On April 11, 2024, at 9:45 am Licensing Program Analyst (LPA) Charmaine Linley arrived at the facility to conduct a Comprehensive Annual Inspection visit. LPA and Ehsan Ebrahim, Facility Administrator, inspected the facility inside and outside. The facility was licensed as a group home on April 22, 2022.

The facility is a single-story residence with a front house and a back house/main house, separated by the garage and driveway. There is at least one week’s supply of nonperishable, and two days’ supply of perishable foods. There is a variety of snacks available for the clients. There are cameras in the common areas and outside areas. The cameras are video only, with no audio. This home provides awake night staff. The facility has a capacity of 20. The group home serves clients between the ages of 12-17 years old, both female and male. There were five clients at the facility during LPA’s visit.

The front house consists of one living room, three offices, two storage rooms, one restroom, one kitchen, and one dining area. The garage is located next to the storage area and leads to the driveway and the back house/main house. The front house is mainly used for offices and the intake area for clients.

The back house/main house has a school room, recreation room, kitchen, dining room, staff room, two offices, medication room/Nurse's station, group room, laundry room, pantry, supply closet, four bathrooms, and ten bedrooms.

A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. The living room, dining room, group room, recreation room, and school room are for clients to use. There is adequate indoor and outdoor activity space. Medication and the


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SUPERVISOR'S NAME: Ann ValenzuelaTELEPHONE: (951) -782-4968
LICENSING EVALUATOR NAME: Charmaine LinleyTELEPHONE: 951-202-1850
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
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: ARROW HOUSE, THE
FACILITY NUMBER: 306090073
VISIT DATE: 04/11/2024
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first aid kit is kept locked in the medication room/Nurses' station, located in the "Main House." The medication room has a locking door, a locking window, and a locking medication cabinet. The facility also has a refrigerator that locks to store medications that require refrigeration. The facility has a fully equipped first aid kit and first aid manual.

The facility's smoke detectors and carbon monoxide detectors were tested and observed to be in working order. Fire extinguishers are properly charged and serviced. There are no guns or weapons in the facility as stated by the Administrator. Disinfectants and cleaning solutions were stored locked in a supply room next to the laundry room. Sharp knives were made inaccessible and stored in a locked cabinet in the supply closet. The staff and client files are maintained and electronically stored, as well physical files. The following required posted items were observed accessible to clients: Facility License, Grievance Procedures, Personal Rights, Visitation policies, Emergency Disaster Plan, and current menu. All hazardous items have been properly made inaccessible.

There are a total of ten bedrooms in the facility and two clients are assigned to each bedroom. There is one client per bed. All bedrooms in the units had adequate beds, lighting, shelves, dressers, and closet space for clients’ belongings. There are sufficient linens, blankets, towels, and pillows. The bathrooms were clean and in good repair. The kitchen’s water temperature was inspected and measured 105 degrees. Bathroom one’s water temperature was inspected and measured 108 degrees. Bathroom two’s water temperature was inspected and measured 106 degrees.

LPA reviewed five out of five client files (C1-C5) (see confidential names list, LIC 811, dated 04/11/2024). LPA conducted three out of five interviews (C1-C3). The client files are maintained in a locked office.

LPA reviewed five out of five staff files (S1-5) (see confidential names list, LIC 811, dated 04/11/2024). LPA interviewed two staff. All staff that work at the facility have Department of Justice, Federal Bureau of Investigation and Child Abuse Index Check clearances. A review of administrative records indicates that the facility has paid their current licensing fees. No deficiencies were cited during today’s visit.

An exit interview was conducted, and a copy of this report was discussed with Ehsan Ebrahim. Due to printer malfunction, LPA emailed the LIC 809, LIC 811, and appeal rights to Ehsan Ebrahim. A copy of the report will be placed in the facility file.
SUPERVISOR'S NAME: Ann ValenzuelaTELEPHONE: (951) -782-4968
LICENSING EVALUATOR NAME: Charmaine LinleyTELEPHONE: 951-202-1850
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
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