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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530074
Report Date: 05/10/2023
Date Signed: 05/10/2023 02:41:01 PM

Document Has Been Signed on 05/10/2023 02:41 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:ALOHA SENIOR LIVING LLCFACILITY NUMBER:
365530074
ADMINISTRATOR:HAMILTON, CAROL KANANIFACILITY TYPE:
740
ADDRESS:8880 TANGERINE AVENUETELEPHONE:
(714) 323-8445
CITY:HEPERIASTATE: CAZIP CODE:
92345
CAPACITY: 4CENSUS: 1DATE:
05/10/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Carol K. Hamilton, LicenseeTIME COMPLETED:
02:50 PM
NARRATIVE
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On 05/10/2023, at 10:23 a.m., Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to conduct a post licensing inspection. LPA met with Licensee Carol K. Hamilton and explained the purpose of the visit. The facility currently has one (1) client in care.

The facility has a total of three (3) bedrooms, two (2) of which are for clients', two (2) bathrooms, one (1) of which is for clients', a kitchen and dining area, a living room, activity areas, and backyard. LPA Nickolas' and the Licensee toured the interior and exterior of the facility. The facility has a swimming pool, which is secured by perimeter fencing and a gate that is locked with a padlock. There is a shaded seating area for client(s) outside. The facility had a working telephone for client(s). The facility has charged fire extinguishers, smoke alarms, and carbon monoxide detectors. A locked centralized storage area for medications. The following were observed of the physical plant:

Client Bedrooms: LPA observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting.


Client Bathrooms: LPA observed grab bars in the shower, and grab bars near the toilet. LPA observed shower chair in the bathtub and non slip skid mats. LPA also observed cleaning supplies stored and locked under the sink.
Kitchen: LPA inspected the kitchen and found dishes, cups, and utensils LPA observed seven (7) days’ supply of nonperishable and two (2) days of perishable food items. The facility menu was available for review.
LPA observed cleaning supplies stored and locked under the sink.
Laundry Room: LPA observed disinfecting supplies stored in the laundry room are locked.
Common (living/activity) areas: LPA observed night lights were maintained in the hallways. There is adequate seating in the common areas. The facility had a supply of activities for the clients. LPA observed that the physical plant is clean, in good repair, and free of any tripping hazards
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
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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Document Has Been Signed on 05/10/2023 02:41 PM - It Cannot Be Edited


Created By: Rayshaun Nickolas On 05/10/2023 at 01:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: ALOHA SENIOR LIVING LLC
FACILITY NUMBER: 365530074

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above, by ensuring that everyone residing at the facility obtained a criminal records clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2023
Plan of Correction
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Licensee shall ensure that all individuals residing at the facility requests a live scan. The licensee was advised that their spouse cannot reside at the facility until the Licensee's spouse has a criminal records clearance. Proof of the correction shall be submitted to the regional office (RO) by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023


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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ALOHA SENIOR LIVING LLC
FACILITY NUMBER: 365530074
VISIT DATE: 05/10/2023
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 During today's inspection, LPA discovered that the Licensee's relative resided at the facility without a criminal records clearance. LPA conducted a records review and confirmed that the Licensee's relative does not have a criminal records clearance with our agency.

Based on interview, record's review, and observation during today’s inspection, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations (CCR).

A $500.00 civil penalty was also assessed based on the Licensee’s relative residing at the facility without a criminal records clearance.

An exit interview was conducted and a copy of this report, LIC 809D, and Appeal Rights were provided.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
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