<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005983
Report Date: 05/25/2021
Date Signed: 05/25/2021 10:01:11 AM

Document Has Been Signed on 05/25/2021 10:01 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LA PALMA HOMECAREFACILITY NUMBER:
306005983
ADMINISTRATOR:BULLER, KATHRINAFACILITY TYPE:
740
ADDRESS:1418 W LA PALMA AVETELEPHONE:
(714) 833-5911
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 5DATE:
05/25/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Kathrina Buller, Garry BullerTIME COMPLETED:
10:16 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Joseph Alejandre made this announced visit for the purposes of conducting a Pre-licensing inspection. LPA met with applicant Kathrina Buller and Garry Buller. LPA was granted entry and toured of the facility. Facility is to operate a Residential Care Facility for the elderly. Capacity is for 6 non-ambulatory residents. Application was submitted to CCL on 03/19/2021. LPA observed the following: Structure. This is a one story home. Facility is a 6 bedroom, 2 bathroom, single story house with an attached garage that is being used for storage and kept locked. Facility telephone number is 714-833-5911. Resident Bedrooms. The client bedrooms are spacious and will easily accommodate the client's furnishings. Lamps & chairs for each client bedrooms inspected. Bathrooms. both were clean, faucets and toilets were operational. Linens & Hygiene Supplies. linens were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. seven day nonperishable food supply and 2 day perishable food supply on hand. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested operational. Appliances. Stove burners, microwave, washer, and dryer are all operational. Knives: Locked/stored in the kitchen cabinet. Toxins: observed locked in the cabinet. Water temperature. Tested 114 degrees Fahrenheit in bathroom #1 and 105 degrees Fahrenheit in bathroom #2. Medication cabinet is locked. First-Aid Kit & Activity Supplies. observed and available. Resident & Staff Files secured on site, no files reviewed. Exit gate from the back yard/driveway to the front of the house is operational and free of obstacles. Fire clearance was approved by Anaheim Fire Inspector Alicia Badosa on 05/07/2021. LPA observed the following, Fireplace in the living room did not have a screen. Applicant was informed the item listed above must be corrected in order for the facility to meet Title 22 Division 6 of the California Code of Regulations. Applicant agreed to contact LPA for follow up inspection. LPA explained the process of this application and also about post licensing visit once the facility is licensed. Applicant was informed today that the final approval will be processed by the CAU supervisor in Sacramento. Component III was waived during the visit due to applicant is a current licensee for a licensed RCFE facility and in compliance status, supervisor approved. An exit interview was conducted and a copy of this report, LIC809 was explained and provided to applicant Kathrina Buller.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1