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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006096
Report Date: 02/22/2022
Date Signed: 02/23/2022 07:35:39 AM

Document Has Been Signed on 02/23/2022 07:35 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:LOLA SENIOR GUEST HOMEFACILITY NUMBER:
306006096
ADMINISTRATOR:DINH, KEVIN DINOFACILITY TYPE:
740
ADDRESS:8681 LOLA AVENUETELEPHONE:
(714) 300-4540
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY: 6CENSUS: 0DATE:
02/22/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Licensee/Administrator Kevin Dino DinhTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Albert Marin conducted an announced Pre-Licensing visit. LPA was granted entry; and met with Licensee / Administrator (AD) Kevin Dino Dinh. .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 11, 2022, The Orange County Fire Authority granted a fire clearance of 6 nonambulatory and of which one may be bedridden.

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 four bathrooms and provided with with hand rails and non- skid floor mats, and fixtures in good repair. Hot water was measured at 115 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 where the washer and dryer unit were and provided with locked door. Facility had video surveillance cameras installed in common areas. 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; and a pool feature surrounded by permanent steel fence and locked access doors. Facility had parking space within the facility premises for guest and visitors.

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SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
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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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: LOLA SENIOR GUEST HOME
FACILITY NUMBER: 306006096
VISIT DATE: 02/22/2022
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LPA Marin conducted the Component III orientation with Licensee / Administrator Kevin Dino Dinh.

For this visit, the facility was observed to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations.

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 Dinh and copy of this report was left in the facility.

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SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022
LIC809 (FAS) - (06/04)
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