306006292-7-27-2023-22-AS-DLMN-CU5U5K-20230727151652

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006292
Report Date: 07/27/2023
Date Signed: 07/27/2023 03:17:13 PM

Document Has Been Signed on 07/27/2023 03:17 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	CASA GRANDE		FACILITY NUMBER:	306006292
ADMINISTRATOR:	SWEENY, ROY		FACILITY TYPE:	740
ADDRESS:	2112 E. VALLEY GLEN LANE		TELEPHONE:	(714) 363-3257
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY: 6		CENSUS: 0	DATE:	07/27/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:06 PM
MET WITH:	Roy Sweeny - Administrator		TIME COMPLETED:	03:20 PM

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) Dwayne Mason Jr. made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility at 1:00pm and was greeted and granted entry by designated Administrator (AD) Roy Sweeny. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden clients was received by Community Care Licensing (CCL) on 12/22/2022. Structure: The facility is a one-story home with six resident bedrooms, three bathrooms, three half bathrooms, four staff bedrooms, living room, kitchen, dining room, enclosed patio, side patio, laundry room, an attached two car garage, backyard, storage room, and two storage sheds. LPA observed the storage room, storage sheds, garage and laundry room to be inaccessible to residents. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the living room. There is a back yard with one exit gate on the Northwest side of the house. There are two shaded seating areas in the backyard. LPA did not observe any obstacles or hazards in the backyard. Client Bedrooms: All resident bedrooms had the required furnishings. LPAs observed facility has linens and blankets for all beds. LPA observed all windows were screened. Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked in the kitchen and laundry room. Medications, First-Aid Kit & Book: Medication will be stored in a locked cabinet in the kitchen. First aid kit is mounted on the wall in the kitchen near the medication cabinet. The first aid kit has all the required elements. Resident & Staff Files: Records will be kept locked in the cabinet in the kitchen. The Plan of Operation was not accessible during the time of the Pre-Licensing visit. The applicant must send LPA a copy of the Plan of Operation by the assigned due date in order to be ready for license.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CASA GRANDE	FACILITY NUMBER: 306006292
	VISIT DATE: 07/27/2023

NARRATIVE

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Fire Extinguisher: LPA observed two fire extinguishers to be fully charged as indicated by the arrow pointing in the green zone.

Reading Material, Games, Equipment & Materials: The facility has activity materials that will be kept in the enclosed patio. Materials for resident use include board games.

Fire clearance: Was approved by a fire inspector of Orange County Fire Department on 01/26/2023.

Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements. A copy of the presentation was provided to the applicant.

Bathrooms: All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 116.6 degrees Fahrenheit in the full bathroom nearest to Resident Room 2. Hot water measured at 107.6 degrees Fahrenheit in the half bathroom inside Resident Room 3. Hot water measured at 107.2 degrees Fahrenheit in the half bathroom inside Resident Room 4. Hot water measured at 109.9 degrees Fahrenheit in the full bathroom accessible from Resident Rooms 5 and 6. Hot water measured at 109.9 degrees Fahrenheit in the full bathroom between the staff rooms. Hot water measured at 115.8 degrees Fahrenheit in the half bathroom between the staff rooms. There is a sink in the separated staff room. Hot water at this sink measured at 115.7 degrees Fahrenheit.

Linens & Hygiene Supplies: A supply of extra linen is stored in the staff room between the kitchen and Resident Room 1.

Emergency Phone Numbers, Exit Plan & Menu: Posted and available for review an emergency disaster plan with means of exiting and emergency phone numbers listed.

Food Service: There is a supply of 7-day of non-perishable food on hand.

Smoke Detectors: Smoke detectors were observed to be dual Smoke & Carbon Monoxide detectors that are stationed throughout the home. The dual detectors were tested and observed to be operational.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CASA GRANDE	FACILITY NUMBER: 306006292
	VISIT DATE: 07/27/2023

NARRATIVE

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Appliances: Gas five burner stove with 1 oven, 1 refrigerator, dish washer, microwave, washer, and dryer are operational.

The following correction is needed before applicant is ready for license:

1. Send LPA a copy of Plan of Operation

The due date for this correction is Thursday, August 3, 2023 by close of business (COB)

Exit interview was conducted and a copy of this report was provided to designated AD.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

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