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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004668
Report Date: 05/01/2024
Date Signed: 05/01/2024 04:56:22 PM

Document Has Been Signed on 05/01/2024 04:56 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/
DIRECTOR:
LACY FADDOULFACILITY TYPE:
740
ADDRESS:651 PRIMROSE STREET S.TELEPHONE:
(949) 682-5229
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 4DATE:
05/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Valesca YahairaTIME VISIT/
INSPECTION COMPLETED:
05:05 PM
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Licensing Program Analysts (LPAs) Jerome Haley and Edward Kim conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPAs were greeted and granted entry by staff and explained the reason for the visit. Staff contacted Administrator (AD) Lacy Faddoul was unable to attend todays visit.

During the inspection, LPA Haley observed all client bedrooms and bathrooms. All client bedrooms had the necessary elements and were in compliance with regulation guidelines. Hot water temperatures were measured at 145.5 degrees Fahrenheit and 134.4 degrees Fahrenheit. No hazardous items were observed in the client bathrooms.

In the kitchen, knives and sharp objects are kept locked in a toolbox in a kitchen cabinet. A perishable food supply that meets regulation requirements was observed in the refrigerator. A non-perishable food supply that meets regulation requirements was observed in the cabinets.

The garage had a clear walkway free of obstruction. Hazardous cleaning materials are stored in the locked garage along with several other facility items like adult diapers, walker, wheelchair, and a bike. A washer and dryer was observed. The backyard was clean, organized, and walkways were free of obstruction. A shaded area with a table and chairs was observed.

A fully charged fire extinguisher was observed mounted on the wall above the locked cabinets in the living room used to store medication, staff, and resident files.

Due to time constraints, the annual inspection was ended today and will be continued. Deficiencies observed and photographed during the tour of the physical plant and review of the staff roster will be cited at the conclusion of the annual inspection.

An exit interview conducted, and a copy of this report was provided to staff.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2024
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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