Facility Evaluation Report

This is an amended report made to obtain signatures.

Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection for an initial pre-licensing. LPA arrived at the facility and was greeted and granted entry by Administrator Cole Dyar (AD). An application to operate a Social Rehabilitation Facility (SRF) for (6) capacity, (6) ambulatory, (0) non-ambulatory, and (0) bedridden clients was received by Community Care Licensing (CCL) on 1/22/2024.

The facility is a two-story home with three shared client bedrooms, three bathrooms, living room, kitchen, dining room, nurses station, offices, staff bathroom, backyard and attached two car garage. There are two exit gates in the back yard. The backyard has a shaded seating area. All client bedrooms had the necessary furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. The bathrooms have working plumbing. Hot water measured at between 105 and 120 degrees Fahrenheit in all bathrooms. LPA observed toxins are inaccessible to clients and will be stored in locked cabinets in the garage. Medication and First Aid Kit are stored in a locked cabinet in the Nurse's Station. LPA observed the fire extinguishers to be fully charged as indicated by the arrow pointing in the green zone. Extinguishers were serviced on 10/10/2024. Fire clearance was approved by a fire inspector of the Fountain Valley Fire Department on 3/18/2024. LPA provided the Component III presentation to provide information about how to operate the facility within compliance. The facility has a games, art supplies, puzzles, electronics and more for activities as well as an activity calendar. A supply of extra linen and hygiene supplies are stored in the staff office closet and garage. Emergency Phone Numbers, Exit Plan, Activity Calendar and Menu are posted and available for review. There is 2-day supply of perishable food and a 7-day supply of non-perishable food on hand. Smoke detectors and carbon monoxide detectors were tested and observed to be operational.

The designated AD was notified that the final application approval will be issued by the Centralized

Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided.