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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006153
Report Date: 10/20/2022
Date Signed: 10/21/2022 01:49:37 PM

Document Has Been Signed on 10/21/2022 01:49 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:CALANGI, KARMIANFACILITY TYPE:
740
ADDRESS:17072 SAGA DRIVETELEPHONE:
(714) 683-4617
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 6CENSUS: 0DATE:
10/20/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Karmian Calangi, AdministratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA), Kathrina Chin made an announced visit for a second pre-licensing evaluation. LPA met with Janella Cervania, Applicant and Karmian Calangi, Administrator. The first pre-licensing inspection was made on September 13, 2022 and several corrections were needed.

The facility has four bedrooms and two full bathrooms and one half bath. This is a single story with a two car garage. 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.

The following items have been corrected.

1) The air conditioning was fixed.
2) A fire protective screen was placed in front of the fire place.
3) The facility posted an Ombudsman poster and the Let Us Know poster.
4) The facility posted activity calendars, theft and loss policy, residents rights, admission agreement, and emergency plans.
5) The hot water temperature was measured at 112 degrees F.
6) The facility has a COVID-19 screening station by the entrance.
7) The facility has more than a 30 day supply of PPE.
8) There is a tweezer inside the first aid kit and a first aid manual by the first aid kit.
9) There are two outdoor patio tables with umbrellas for shade.
10) Each bathroom has hand washing signs posted.
11) Remove all debris by the exit and side gate

(Continued on LIC 809C)
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kathrina Chin
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022
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: 10/20/2022
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12) All six beds have mattress pads and blankets.
13) The large holes in the bedframes have been covered.
14) The trash and debris in the garage have been cleared.
15) Karmian Calangi, Administrator is now associated to the facility.


The Pre-Licensing evaluation has been completed. It appears this facility meets the requirements for licensure. The license will be granted upon completion of a final review and approval from the Application Specialist.

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

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC809 (FAS) - (06/04)
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