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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006220
Report Date: 02/15/2023
Date Signed: 02/15/2023 11:25:59 AM

Document Has Been Signed on 02/15/2023 11:25 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:MARY'S LOVING CARE AFACILITY NUMBER:
306006220
ADMINISTRATOR:HAN, XUFACILITY TYPE:
740
ADDRESS:341A 16TH PLACETELEPHONE:
(646) 549-5035
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 6CENSUS: 5DATE:
02/15/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Xu HanTIME COMPLETED:
11:40 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 Applicant (AP) Xu Han, 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 08/01/2022. This is a change of ownership with persons in care.

During the inspection, LPA and AP observed the following: Structure. This is a one-story home. Facility is a 4-bedroom, 4-bathroom, 1 story house with attached garage that is being used for storage. Facility telephone number is (949) 200-9378. Resident Bedrooms. The 4 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Lamps, chairs, linens, and storage for each resident bedroom inspected. Staff Bedrooms. There are no staff bedrooms. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 114.8 and 117.5 F degrees. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. 2 days perishable and 7 days nonperishable food supply reviewed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen drawer. Toxins: observed locked in the garage and under the kitchen sink. Medication cabinet is locked. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files. LPA reviewed resident and staff files. Fire clearance was approved by City of Costa Mesa Fire Prevention Inspector Ben Castillo on 12/08/2022. Backyard. Backyard exit gate is operational and unlocked. Component III was completed with AP during today’s inspection. Facility is currently operating under the liability insurance of current facility IRVINE COTTAGES / LANEY'S COTTAGES EASTSIDE A (306005954). AP will switch liability insurance to new facility once the application is approved.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2023
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: MARY'S LOVING CARE A
FACILITY NUMBER: 306006220
VISIT DATE: 02/15/2023
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During the inspection, LPA and AP observed that there was no patio cover or outdoor seating for residents. AP agreed to purchase and install outdoor seating and an umbrella for provide seating and shade for the residents.

During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AP was informed the items listed above must be completed for the facility to meet Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to AP.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023
LIC809 (FAS) - (06/04)
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