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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006025
Report Date: 08/10/2021
Date Signed: 08/10/2021 05:21:05 PM

Document Has Been Signed on 08/10/2021 05:21 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:VIOLET RESIDENTIAL CAREFACILITY NUMBER:
306006025
ADMINISTRATOR:AMURAO, VIOLETAFACILITY TYPE:
740
ADDRESS:12141 ORA DR.TELEPHONE:
(714) 583-8172
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 6CENSUS: 5DATE:
08/10/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Violeta AmuraoTIME COMPLETED:
05:35 PM
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Licensing Program Analyst (LPA) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Administrator (AD) Violeta Amurao, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 06/08/2021. This is a change of ownership.

During the inspection, LPA and AD observed the following. Structure. This is a one-story home. Facility is a 6-bedroom, 4-bathroom, 1 story house with attached garage that is being used for storage. There is a back yard with a patio cover for the clients. Facility telephone number is (714) 583-8172. Bedrooms Residents. The 5 client bedrooms are spacious and will easily accommodate the client's furnishings. Lamps, chairs, linens, and storage for each client bedroom inspected. Bedrooms staff. The 1 staff bedroom is spacious and will easily accommodate the staff’s furnishings. Lamps, chairs, linens, and storage for each staff bedroom inspected. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 111 to 114 F degrees. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. 2 days perishable and 7 days nonperishable food supply observed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detector/carbon monoxide detector. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked/stored in the kitchen cabinet. Toxins: observed in the locked cabinet in the garage. Medication cabinet is locked. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files. LPA reviewed resident and staff files. Fire clearance was approved by Orange County Fire Authority Inspector Erik Solsvik on 07/08/2021. Backyard. Backyard exit gate is operational and unlocked. Backyard has shaded area for outdoor activities and sufficient seating for residents. Component III was completed with AD during today’s inspection. Facility is currently operating under the liability insurance of current facility CRYSTAL RESIDENTIAL CARE (306005624). AD will switch liability insurance to new facility once the application is approved.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2021
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VIOLET RESIDENTIAL CARE
FACILITY NUMBER: 306006025
VISIT DATE: 08/10/2021
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During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AD was informed today that the facility is ready for licensure and final approval will be processed by the CAU supervisor in Sacramento. An exit interview was conducted and a copy of this report was discussed with and provided to AD.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
LIC809 (FAS) - (06/04)
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