Facility Evaluation Report

Licensing Program Analyst (LPA) Shobhana Frank conducted announced inspection for the purpose of conducting a pre-licensing inspection and COMP III. LPA met with and discussed the

purpose of the inspection. LPA Frank toured the facility along with the Licensee Maria Rivera.

Application for change of Corporation was submitted to Community Care Licensing on 04/06/22.

LPA observed COVID - visitation station equipped with hand sanitizer, thermometer, Gloves, visitors log,

During the inspection, LPA observed the following.

This is a single story home. Facility is a 4 bedroom and 2 bathroom, house with attached garage that is

being used for storage. There is a back yard with a patio cover for the residents. Backyard exit gate is operational and unlocked. Backyard has shaded area for outdoor activities and

sufficient seating for residents. LPA observe the facility to be clean and in good repair, Physical Plant and Safety of Environment/Operational as CCL Requirements.

Facility telephone number is 714-373-4668. The 4 residents bedrooms are spacious and easily accommodate the residents furnishings. Lamps, chairs, linens, and storage for each residents bedroom. Bathrooms were inspected and observed to be clean, faucets and toilets were operational. Water temperature was tested 109.5 F degrees. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers 714-679-8522, Exit Plan & Menu: Reviewed. Food Service. 2 days perishable and 7 days nonperishable food supply observed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detector/carbon monoxide detector. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked/stored in the kitchen cabinet. Toxins: observed in the locked cabinet in the garage. Medication cabinet is locked. First-Aid Kit & Activity Supplies: observed and available. Fire clearance was approved by Orange County Fire Authority on 2/22/22.