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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006166
Report Date: 08/24/2022
Date Signed: 08/24/2022 03:48:08 PM

Document Has Been Signed on 08/24/2022 03:48 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:INNER CIRCLE ASSISTED LIVING #1, LLCFACILITY NUMBER:
306006166
ADMINISTRATOR:LIN, ERICFACILITY TYPE:
740
ADDRESS:18332 SERRANO AVETELEPHONE:
(714) 331-7950
CITY:VILLA PARKSTATE: CAZIP CODE:
92861
CAPACITY: 6CENSUS: DATE:
08/24/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Eric LinTIME COMPLETED:
04:05 PM
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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 Eric Lin. An initial application to operate a Residential Care Facility for the Elderly was received by CCL on 03/04/2022 for a capacity of five non-ambulatory and one bedridden resident. Facility has a covid screening area in the entrance of the facility. LPA observed the PPE supply in the facility.
LPA Lyman along with Licensee/ Administrator toured the facility at 2:08 PM and observed the following:
Structure: Facility is a one story, 6 bedroom, 5 bathroom house with an unattached garage and a white exterior. 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 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 a secured area for toxins and sharps in the garage. Water Temperature: Tested and recorded between 105.4 and 108.3 degrees F. in facility bathrooms. Emergency Supplies: LPA observed emergency food in the facility. 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. Facility to use a medication administration record. Resident & Staff File: Records are stored in a secured file cabinet in the living room. 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: INNER CIRCLE ASSISTED LIVING #1, LLC
FACILITY NUMBER: 306006166
VISIT DATE: 08/24/2022
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Reading Material, Games, and Equipment: LPA observed a sample activity schedule with activities such as exercise, gardening, and arts and crafts. Backyard: LPA observed a large, clean backyard. Fire Clearance: Approved for five non-ambulatory residents and one bedridden resident on 05/10/2022.

During the visit, LPA observed the following:
  • Facility does not have shaded outdoor seating/ visitation area in outside area. Please obtain seating.
  • Facility does not have hand washing signs in restrooms or covid signage outside entrance. Please post signage.
  • Facility does not have emergency water. Please obtain an ample emergency water supply.
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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