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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006163
Report Date: 08/24/2022
Date Signed: 08/25/2022 06:45:11 AM

Document Has Been Signed on 08/25/2022 06:45 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:A+ CARE HOME FULLERTONFACILITY NUMBER:
306006163
ADMINISTRATOR:MCKERNAN, JEANFACILITY TYPE:
740
ADDRESS:2401 THORN PLACETELEPHONE:
(949) 481-6757
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY: 6CENSUS: 0DATE:
08/24/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jean McKernan and Nori WhittakerTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Administrator/ Licensee Jean McKernan. Co-Licensee Nori Whittaker was present as well. An initial application to operate a Residential Care Facility for the Elderly was received by CCL on 03/16/2022 for a capacity of six bedridden residents. Facility has a covid screening area in the entrance of the facility as well as covid signage at entrance to facility. LPA observed the PPE supply in the facility.
LPA Lyman along with Licensees/ Administrator toured the facility at 9:38 AM and observed the following:
Structure: Facility is a one story, 6 bedroom, 5 bathroom house with an attached garage and a cream exterior. Bedrooms 1 and 2 are designated as shared on floor plan. Licensee to update floor plan to indicate the bedroom as shared only. The exit gates are closed and unlocked. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: Rooms will be single and double occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Facility has sanitizer and paper towels in the restrooms. Linens & Hygiene Supplies: Facility has ample bedding and towels for residents in care. Emergency Phone Numbers and Exit Plan: Posted in entrance of facility. Food Service: Facility does not have 2 day perishables and 7 day non-perishables as there are no residents present. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguishers are mounted and charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: Facility has multiple secured areas for toxins and sharps. Water Temperature: Tested and recorded between 125.2 and 82.5 degrees F. in facility bathrooms. Emergency Supplies: LPA observed emergency food and water as well as a posted emergency disaster plan. Medications, First-Aid Kit & Book: First aid kit observed contained all required items including a first aid guide. Medication is stored and locked in a locked cabinet. CONTINUED ON LIC 809C DATED 08/24/2022
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2022
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: A+ CARE HOME FULLERTON
FACILITY NUMBER: 306006163
VISIT DATE: 08/24/2022
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Facility to use a medication administration record. Resident & Staff File: Records are stored in a secured file cabinet off the dining room. Reading Material, Games, and Equipment: LPA observed activities such as games. Facility to tailor activities to resident preference. Backyard: LPA observed a large, clean backyard. Fire Clearance: Approved for six bedridden residents on 06/08/2022.

During the visit, LPA observed the following:
  • Water temperature is out of compliance. Please adjust water temperature to be between 105 and 120 degrees F.
  • Facility restrooms do not have hand washing signs. Please post signage.
  • Facility does not have outdoor shaded seating. Please obtain seating.
  • Facility to update floor plan and forward to LPA.
Licensee to complete corrections by 08/31/2022.


Component III conducted during the visit. Facility is not ready to be licensed. Licensee to contact LPA when corrections have been made.


Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC809 (FAS) - (06/04)
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