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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006109
Report Date: 03/17/2022
Date Signed: 03/17/2022 01:56:03 PM

Document Has Been Signed on 03/17/2022 01:56 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:GOLDEN LIFE MANOR IFACILITY NUMBER:
306006109
ADMINISTRATOR:NUNEZ, LORENZIFACILITY TYPE:
740
ADDRESS:2315 E. PURITAN LANETELEPHONE:
(562) 544-9167
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 5CENSUS: 0DATE:
03/17/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lorenzi Nunez, Prospective licenseeTIME COMPLETED:
03:00 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made a scheduled visit to the facility for the purpose of conducting the pre-licensing verifications required for an initial application.
At approximately 1:00pm, LPA was greeted upon arrival by the applying licensee Lorenzi Nunez and granted entry. Facility is a one-story house with three (3) bedrooms assigned to residents.

CCLD staff started by touring the physical plant. Hallways are clear of clutter and debris; adequate furnishing elements are being provided to the clients. The two (2) shared bathrooms used by clients are free of toxics and non-slip maps and grab bars have been installed. The water temperature is measured to be 111 degrees in the kitchen and 120 degrees in both shared bathrooms. An ample supply of linen is available to residents. Smoke detectors are present in each room and found to be operational as well as carbon monoxide detectors. The exterior of the physical plant is also free of clutter and debris. A single gate at the side of the house is self-latching but can be easily opened in case of evacuation.

An ample supply of perishable and non-perishable food is on hand as well as emergency food and water supply, stored in the garage. Weekly nutrition plans are displayed in the kitchen. A sufficient supply of PPE is also stored in the kitchen cabinet. Cleaning supplies and toxics are kept under lock. Medication assigned to each client will be stored and locked in the kitchen. A fireplace screen will be acquired and put in front of the fireplace with no delay. Licensee will be providing LPA with proof of installation as soon as possible.
Emergency disaster plan has been provided and reviewed with the licensing application. The mitigation plan has been submitted and will be approved shortly by Community Care Licensing (CCL).

LPA verified all domains of the inspection tool and found no deficiency at this time. The prospective licensee already operates a total of four (4) other licensed facilities, so the Component III has been waived. The facility is ready to be licensed. An exit interview and a copy of the report were provided at the time of the exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2022
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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