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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006253
Report Date: 05/15/2023
Date Signed: 05/15/2023 11:11:44 AM

Document Has Been Signed on 05/15/2023 11:11 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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SENIOR'S RETREAT OF BREA, INC., THEFACILITY NUMBER:
306006253
ADMINISTRATOR:SMITH, LORNAFACILITY TYPE:
740
ADDRESS:311 GUAVA PLTELEPHONE:
(562) 746-7899
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY: 6CENSUS: 0DATE:
05/15/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lorna Smith TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation.

An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden clients was submitted to CCL on 11/02/22.

Structure:
The facility is a one story house with an attached garage with 5 resident bedrooms, 2 full bathrooms, a family/great room, a dining room, a living room, and a kitchen. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with exit walkways on each side of the house with covered seating for the residents.

Air/Heating:
Central air/heating system installed with a central panel to control entire house.

Bedrooms Residents:
Bedrooms will accommodate 6 residents with 4 private rooms and 1 shared room accommodating two clients. Bedrooms #3 has a bathroom.

Bedrooms Staff:
No bedroom designated for awake-staff.

Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SENIOR'S RETREAT OF BREA, INC., THE
FACILITY NUMBER: 306006253
VISIT DATE: 05/15/2023
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Bathrooms:
All bathrooms have a working toilet, wash basin, walk in shower.

Linens & Hygiene Supplies:
Adequate supply of linen stored in bedroom hallway storage.

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. Menus prepared one week prior and listed for food serve for one week.

Food Service:
Adequate supply of 7-day non-perishable and 2-day perishables are stored in the kitchen.

Smoke Detectors:
Smoke detectors and carbon monoxide alert systems are hardwired, were tested and found operational.

Appliances:
Gas four-burner stove, single oven, 1 refrigerator, microwave, dishwasher, washer, and dryer are clean and noted to be operational.

Toxins:
All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are locked and stored underneath kitchen sink and laundry toxins in garage locked.

Water Temperature:
Tested and recorded maintained at a comfortable temperature and the water temperature measures 120.4 Fahrenheit degrees in facility bathrooms.

Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SENIOR'S RETREAT OF BREA, INC., THE
FACILITY NUMBER: 306006253
VISIT DATE: 05/15/2023
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Medications, First-Aid Kit & Book:
Medication and First Aid/Book locked and hallway storage closet upon entry to bedroom hallway.

Resident & Staff Files:
Records will be kept locked with medication closet storage.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation.

Fire clearance:
Was approved on 02/15/23. Facility has 2 fire extinguishers mounted and charged in the entrance of the facility and in kitchen.

Component III:
Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities.

Facility appears to be ready for licensure. Accordingly, LPA will submit file for approval to CCL Supervisor. Exit interview was conducted and a copy of this report was left with the applicant.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3