306006162-8-4-2022-22-AS-JALE-CGYSJ7-20220804135440

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006162
Report Date: 08/04/2022
Date Signed: 08/04/2022 01:54:53 PM

Document Has Been Signed on 08/04/2022 01:54 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:	COLORADO RESIDENTIAL CARE		FACILITY NUMBER:	306006162
ADMINISTRATOR:	FRANCISCO, ANALIE		FACILITY TYPE:	740
ADDRESS:	436 N COLORADO ST		TELEPHONE:	(949) 290-3917
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY: 6		CENSUS: 0	DATE:	08/04/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:	Analie Francisco, Mareties Pontoy, Theresa Bernabe.		TIME COMPLETED:	02:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Joseph Alejandre made an announced visit to conduct the pre-licensing inspection. LPA was greeted and granted entry by the applicants. An application to operate a Residential Care Facility for the Elderly (RCFE) for 6 non-ambulatory, and (0) bedridden residents was received by the Agency (CCL) on 3/15/22. LPA and applicants toured the facility. Structure: The facility is a one story home with 4 resident bedrooms, 1 storage room, living room with a fireplace, an eat in kitchen, laundry room, 2 car garage and 3 bathrooms. Facility telephone phone number is. 714-886-2230. LPA observed the See Something, Say Something poster (PUB 475) in the living room, the poster is visible from the entrance. LPA observed all of the required postings. LPA observed the fireplace in the living room is screened. All exit doors had working auditory alarms. There is a back yard with 1 exit gate on the side of the house. The exit gate is self closing. Resident Bedrooms The resident bedrooms are spacious and will easily accommodate the resident’s belongings. All resident bedrooms had the required furnishings. LPA observed all windows are screened. Signal system There is no signal system. Bedrooms Staff: No staff will be living at the facility. All bedrooms are for residents.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

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: COLORADO RESIDENTIAL CARE	FACILITY NUMBER: 306006162
	VISIT DATE: 08/04/2022

NARRATIVE

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Bathrooms:
All bathrooms have working plumbing and are operational. Hot water measured 113.6 to 114.9 degrees Fahrenheit in all 3 bathrooms.

Linens & Hygiene Supplies:
Adequate supply of linen stored in the laundry room.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Emergency food and water supply is stored in the garage.

Food Service:
LPA observed non-perishable food supply on hand and perishable food supply on hand in the refrigerator.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas four burner stove with oven, 1 refrigerator, microwave, washer, and dryer are clean and operational.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked in the laundry room.

Medications, First-Aid Kit:
Medication will be stored in a locked cabinet in the kitchen. First aid kit is stored with the medication. The first aid kit has all the required elements.

Resident & Staff Files:
Records will be kept locked in in the storage cabinet in the kitchen.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

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: COLORADO RESIDENTIAL CARE	FACILITY NUMBER: 306006162
	VISIT DATE: 08/04/2022

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Backyard, bodies of water & pets:
No bodies of water observed at the facility. No pets will be at the facility. LPA observed the backyard has a covered patio with a table and chairs for residents. No obstacles or hazards observed in the backyard. The backyard exit gate is latched and operational and self closing.

Fire Extinguisher:
All fire extinguishers are fully charged.

Reading Material, Games, Equipment & Materials:
The facility has puzzles and other games for the client’s use, stored in the living room. There is also a television in the living room for residents to watch TV.

Fire clearance:
Was approved by fire inspector Alicia Badosa of Anaheim Fire Department on 6/30/2022.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance and reporting requirements.

No deficiencies observed at the facility. No corrections are required. LPA informed the applicants the physical plant is ready to accept residents. The facility is now ready to be licensed. LPA informed the applicants the final application approval for licensing will completed by the CAB unit in Sacramento. An exit interview was conducted and a copy of the report provided.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC809 (FAS) - (06/04)

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