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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006153
Report Date: 09/13/2022
Date Signed: 09/13/2022 03:54:33 PM

Document Has Been Signed on 09/13/2022 03:54 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:CARE JANELLAFACILITY NUMBER:
306006153
ADMINISTRATOR:PAO, ADRIELFACILITY TYPE:
740
ADDRESS:17072 SAGA DRIVETELEPHONE:
(714) 683-4617
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 6CENSUS: 0DATE:
09/13/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Janella Cervania & Karmian CalangiTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPAs), Kathrina Chin and Jessica Cho made an announced visit for a pre-licensing evaluation. LPAs met with Janella Cervania, Applicant and Karmian Calangi, Applicant/Administrator. The facility has four bedrooms and two full bathrooms and one half bath. This is a single story with a two car garage facility. The inspection is as follows:

A fire clearance was granted on August 23, 2022 for 5 non-ambulatory and 1 bedridden. The facility is requesting for a hospice waiver for 4 residents.

LPAs toured the facility, interior and exterior, including all resident bedrooms. The hot water temperature was tested in the resident bathrooms and observed to be 79.8 degrees Fahrenheit. One fire extinguisher was mounted and charged. Smoke detectors were centrally wired throughout and have been checked by the fire department. Carbon monoxide detectors are operational. There is sufficient supply of linens. There are non-skid mats in the showers.

There was one locked medication closet and one first aid kit. There were several locked closets for storage of toxins and cleaning equipments. All exits have auditory devices. The kitchen area was checked. Karmian Calangi stated that she will post activity calendars, theft and loss policy, residents rights, admission agreement, and emergency plans. The facility needs to post an Ombudsman and Let Us Know posters. LPA reviewed the outdoor area and there were outdoor furniture but no umbrella for shade.


(Continued LIC 9099C)
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kathrina Chin
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2022
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: CARE JANELLA
FACILITY NUMBER: 306006153
VISIT DATE: 09/13/2022
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A second pre-licensing will be scheduled.
The following items need to be corrected prior to licensure:

1) Air conditioning is broken. Karmian Calangi stated that she will have an air conditioning installed.
2) A fire protective screen for the fire place is needed.
3) The facility needs to post an Ombudsman and Let Us Know posters.
4) The facility needs to post activity calendars, theft and loss policy, residents rights, admission agreement, and emergency plans.
5) The facility does not have hot water. The hot water temperature was measured at 79.8 degrees Fahrenheit in all three bathrooms.
6) The facility does not have a COVID-19 screening station.
7) The facility does not have 30 day PPE supplies
8) A tweezer for the first aid kit and first aid manual are needed.
9) A patio umbrella is needed for shade.
10) Post hand washing signs in all bathrooms.
11) Remove all debris by the exit and side gate
12) Mattress pads and blankets are needed for the six beds.
13) Cover up the two holes on the bedframes.
14) Remove all trash and debris in the garage.
15) Please associate Karmian Calangi, Administrator to the facility.



A Component III was completed during the visit with Janella Cervania and Karmian Calangi, Applicants. LPAs reviewed Personnel Policies, Prohibited Health Conditions, Fingerprinting, Abuse Reporting Procedures, In-Service Training, and Medication Procedures.

It appears that this facility does not meet the requirements for licensure. A second pre-licensing visit will be scheduled.

An exit interview was conducted with Janella Cervania and Karmian Calangi, Applicants and a hard copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kathrina Chin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
LIC809 (FAS) - (06/04)
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