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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006091
Report Date: 04/06/2022
Date Signed: 04/06/2022 03:29:35 PM

Document Has Been Signed on 04/06/2022 03:29 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:PRISTINE HOME CAREFACILITY NUMBER:
306006091
ADMINISTRATOR:ALVARADO, MARY JEANFACILITY TYPE:
740
ADDRESS:9252 PACIFIC AVETELEPHONE:
(714) 749-7237
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 0DATE:
04/06/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Licensee/Administrator Mary Jean AlvaradoTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Albert Marin conducted an announced Pre-Licensing visit. LPA met with Licensee / Administrator (AD) Mary Jean Alvarado .LPA stated the purpose of this visit.

The initial application to operate a Residential Facility for the Elderly was received by Centralized Applications Bureau of the Department. On January 6, 2022, The Anaheim Fire Department granted a fire clearance of 6 non-ambulatory. LPA Marin conducted a tour of the interior and exterior portions of the facility and observed the following: Facility is a single level structure. There were no residents in care. There were four private and one shared resident's rooms. Rooms were provided with good lighting system, storage space, furniture in good repair, clean and appropriate linens, and free of any obstruction or tripping hazards. There were two bathrooms which were provided with handrails, non- skid floor mats, and fixtures in good repair. Hot water was measured at 120 degrees Fahrenheit. Common areas were provided with appropriate furniture in good repair and free of any obstruction or tripping hazards. Hallways were well lit. Kitchen appeared clutter free and provided with cooking appliances in good repair. Sharp kitchen items were secured in a locked drawer. Facility met the minimum the two-day perishable and seven-day non-perishable food stock requirements. Cleaning supplies were stored in the garage and rendered inaccessible to residents. Centralized smoke and carbon monoxide detectors were tested to be operational. Auditory exit alarms were in place. Fire extinguishers were mounted and charged. First aid kit was available in the facility. Medication will be stored in a locked cabinet. Personal rights, Let Us Know poster, and resident council rights are posted in common area. For the exterior portions, the facility had adequate shaded areas with furniture in good repair.

LPA Marin conducted the Component III orientation with Licensee / AD Mary Jean Alvarado

For this visit, no correction was necessary for areas observed. The prelicensing visit and Component III orientation are NOW COMPLETE.

LPA Marin will provide a copy of this report to Centralized Applications Bureau for final determination of the application.

LPA Marin conducted an exit interview with AD Alvarado and copy of this report was left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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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