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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700782
Report Date: 09/03/2020
Date Signed: 09/03/2020 02:21:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:7121 MAIN, LLCFACILITY NUMBER:
342700782
ADMINISTRATOR:COLEMAN, ROBERTFACILITY TYPE:
740
ADDRESS:7121 MAIN AVETELEPHONE:
(707) 592-4004
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 0DATE:
09/03/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marie ColemanTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Wolter conducted a prelicensing inspection via tele-visit on 09/03/2020 due to COVID-19 and precautionary measures. LPA met with licensee Marie Coleman. This is a change of ownership however the facility currently has no (0) residents, LPA observed no residents to be residing in the facility during today's tele-visit.

Licensee and LPA toured the facility via video conferencing and observed the following areas: six (6) resident bedrooms, two (2) resident bathrooms, staff room, kitchen, living room, laundry area, and outdoor area. The facility appeared to be in good repair at time of inspection and equipped with smoke detectors throughout the home, carbon monoxide detector is also present. Facility has locked closet for cleaning supplies and a locked cabinet for medications, knives were observed to be inaccessible. Resident bathrooms had required grab bars and non-skid mats. LPAs and administrator discussed what food supply would look like when facility is in operation and licensee understands a 2-day perishable and 7-day non-perishable needs to be on hand at all times.

Facility will utilize ECP-123 program for resident records and as an eMAR, Relias will be used for employee training. Required signs were observed throughout the facility.

Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulations.
Component III was waived as licensee has recently completed one and has other facilities in substantial compliance. LPA will contact the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application.

Exit interview conducted and copy of report was emailed to licensee, signed copy to be returned to Community Care Licensing, a signed copy should be retained for facility records.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2020
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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