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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006178
Report Date: 10/19/2022
Date Signed: 10/19/2022 10:39:27 AM

Document Has Been Signed on 10/19/2022 10:39 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:POLLY'S PLACEFACILITY NUMBER:
306006178
ADMINISTRATOR:VALENCIA, POLLYFACILITY TYPE:
740
ADDRESS:2143 W. FIR AVE.TELEPHONE:
(949) 412-2579
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 0DATE:
10/19/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Polly ValenciaTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Administrator (AD) Polly Valencia, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 04/07/2022. This is an initial application with no residents in care. This is the second pre-licensing inspection. Please see LIC809 dated 10/12/2022.

During the initial pre-licensing inspection, LPA and AD observed that the room designated as an office on the floor plan contained 2 beds. AD stated that there are no staff bedrooms, but that the office was intended to be used as a staff break room, the beds were there for break purposes, and no one would sleep in that room overnight. AD also stated that overnight supervision would be provided by wake overnight staff.

After the initial pre-licensing inspection, AD explored the possibility of having the office fire cleared as a staff bedroom, but chose to move forward with the current floor plan and removed the beds from the office.

During today’s inspection, LPA and AD inspected the facility and observed that the room designated as an office on the floor plan no longer contains any beds. The office now contains a desk and couch. AD confirmed that overnight supervision will be provided by wake overnight staff.

During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AD was informed today that the facility is ready for licensure and final approval will be processed by the CAB supervisor in Sacramento. An exit interview was conducted and a copy of this report was discussed with and provided to AD.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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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