<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006280
Report Date: 05/04/2023
Date Signed: 05/08/2023 06:54:51 AM

Document Has Been Signed on 05/08/2023 06:54 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:SHASTA RESIDENTIAL CAREFACILITY NUMBER:
306006280
ADMINISTRATOR:DINH, KEVIN DINOFACILITY TYPE:
740
ADDRESS:16274 SHASTA STTELEPHONE:
(714) 300-4540
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 0DATE:
05/04/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Kevin Dino DinhTIME COMPLETED:
10:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Lydia Martinez conducted this announced visit for the purpose of conducting a Pre-Licensing inspection. LPA Martinez met with Applicant (AP) Kevin Dino Dinh and a tour of the inside and outside of the facility was completed.

Facility is to operate a Residential Care Facility for the Elderly (RCFE). The Application was submitted to Community Care Licensing on 12/02/2022. Facility is a one story, 4 bedroom, 3 full bathroom home with an attached 2-car garage. Facility will have hourly staff. A Fire Clearance was granted for 5 non-Ambulatory, and one Bedridden Residents on 02/28/2023. Bedroom #4 is designated for Bedridden. Facility is secured by a fence around the property. Adequate seating is available in the dining room as well as the living room. Bedrooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms have wash basin and walk in showers. Linen supply is ample supply for residents. Applicant understands facility will have a two day perishables and seven day non-perishables food supply when Residents present. Smoke detectors are centrally wired and are operational. Carbon Monoxide was operational. Fire extinguishers are mounted and charged. Stove, oven, refrigerator, dishwasher, microwave, washer, and dryer are clean and operational. Toxins are locked/stored under kitchen sink. Hot water in bathroom is within regulatory requirements. First Aid Kit observed contained all required items. Medication will be stored in the locked hallway cabinet. The facility will have movie nights, bingo, walking and puzzles for activities. Facility has a covered patio with table and chairs. Side exit gate is unlocked and self latching. The Component III was waived as Applicant is an existing Administrator for other existing facility.

LPA noted a discrepancy with the floor plan approved by the Fire Department; there is a built-in room in the garage not drawn on the floor plan. LPA explained to Applicant that clarification from Fire Inspector is needed before the facility can be ready for licensure based on the inspection. Applicant stated he will knock the walls down and contact LPA when ready for 2nd walk through. An exit interview was conducted and a copy of this report will be sent to email on file.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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 1