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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005499
Report Date: 12/09/2024
Date Signed: 12/09/2024 11:32:12 AM

Document Has Been Signed on 12/09/2024 11:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SIGNATURE RESIDENCE, INC. THEFACILITY NUMBER:
306005499
ADMINISTRATOR/
DIRECTOR:		FARIS, KOLALEHFACILITY TYPE:
740
ADDRESS:2727 WAVECREST DRTELEPHONE:
(949) 220-1412
CITY:CORONA DEL MARSTATE: CAZIP CODE:
92625
CAPACITY: 6CENSUS: 6DATE:
12/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:23 AM
MET WITH:Kolaleh"Koli" Farris, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1. During today’s visit, LPA met with Kolaleh Farris, Administrator.

The facility is a single-story home with five bedrooms and three resident bathrooms with an approved fire clearance for six non-ambulatory residents of which one may be bedridden and three are approved for hospice. The facility currently has a census of six residents in care with one resident on hospice.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in three of three resident bathrooms, and testing auditory devices on all exits. LPA observed shaded seating areas in the patio with an enclosed coop for chickens The hot water temperature measured between 113.0 and 119.3 degrees Fahrenheit and the centralized smoke and carbon monoxide detectors were operational. The fire extinguisher is charged and was serviced on August 2, 2024. The facility’s last fire drill was conducted in September 2024.

LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. The First Aid kit had the required items and the facility has a First Aid Book.

LPA reviewed three of three staff training and fingerprint records and conducted a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on April 11, 2026.
(Continued on LIC 809-C)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SIGNATURE RESIDENCE, INC. THE
FACILITY NUMBER: 306005499
VISIT DATE: 12/09/2024
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(Continued from LIC 809)

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Kolaleh "Koli" Farris, Administrator and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC809 (FAS) - (06/04)
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