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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004668
Report Date: 04/28/2022
Date Signed: 04/28/2022 12:27:40 PM

Document Has Been Signed on 04/28/2022 12:27 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PRIMROSE RESIDENTAL CAREFACILITY NUMBER:
306004668
ADMINISTRATOR:LACY FADDOULFACILITY TYPE:
740
ADDRESS:651 PRIMROSE STREET S.TELEPHONE:
(949) 682-5229
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 4DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:House Manager Iula PerezTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection to this facility. LPA met with House Manager (HM) Iula Perez and stated the purpose of this visit.

This facility is one level structure and licensed for capacity of six, with two non-ambulatory and with hospice waiver for two. For this visit, there was no resident under hospice care.

LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. LPA toured the interior and exterior portions of the facility. LPA observed four residents in care and one staff member on the floor. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide, and auditory exit alarms were tested to be operational. Bathrooms were provided with handrails and nonskid floor mats. Hot water was measured at 112 degrees Fahrenheit. Medications, cleaning supplies and sharp kitchen items were inaccessible to residents in care. Facility met the minimum 2 day perishable and 7 day non- perishable food stock requirements. LPA observed personal protective equipment in place. Fire extinguisher was mounted and charged. For the exterior portion, facility had outside furniture in good repair. Grounds were free of tripping hazards. LPA Marin reviewed the COVID 19 mitigation plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that an support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. Administrator's certificate is valid until May 9, 2022.

No citation was issued during this visit.

LPA Marin conducted phone exit interview with AD Lacy Faddoul. HM Perez signed and received this report.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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