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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881246
Report Date: 04/25/2022
Date Signed: 04/25/2022 01:30:23 PM


Document Has Been Signed on 04/25/2022 01:30 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:ORCHARD SENIOR LIVINGFACILITY NUMBER:
361881246
ADMINISTRATOR:GUEVARRA, MARYDESFACILITY TYPE:
740
ADDRESS:4287 ORCHARD STTELEPHONE:
(213) 618-0938
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY:6CENSUS: 5DATE:
04/25/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Marydes GuevarraTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Jennifer Semin conducted an announced visit to complete a pre-licensing inspection and component III. LPA met with Licensee/Administrator, Marydes Guevarra. The application is for a Residential Care Facility for the Elderly for six (6) non-ambulatory residents and a hospice waiver for six (6).

A tour of the pending facility was conducted inside and out. Overall, the pending facility is clean and of newer construction. There no pools, bodies of water, firearms or ammunition. LPA observed all bedrooms to be appropriately furnished with adequate lighting. Bathroom toilets, showers and tubs have grab bars and non-skid mats. The hot water temperature was measured in the residents bathroom at 120 degrees Fahrenheit. LPA observed food storage and preparation areas to be clean and sanitary. Refrigerator and freezer temperatures are maintained at appropriate temperatures. All appliances are clean and operating properly. There is a sufficient supply of linens, towels, and personal hygiene items. The first aid kit was reviewed; all items are present including a First Aid Manuel. LPA observed an adequate supply of recreation and leisure items and activities, The backyard is completely enclosed with functioning gate to exit to front yard. Outdoor space is suitable for resident use that includes a covered patio with a table and chairs. LPA observed the fire extinguishers to be recently serviced and completely charged. Smoke alarms and carbon monoxide detectors are present and functional. Medications are centrally stored and secured in a locked cabinet. All hazardous materials such as, cleaning and disinfecting supplies, knives and other sharps are locked and inaccessible to residents. All required forms are posted in a common area.

Pre-Licensing is complete and has no deficiencies.

An exit interview was conducted where this report was discussed and provided to Ms. Guevarra.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022
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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