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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006299
Report Date: 05/09/2023
Date Signed: 05/09/2023 09:57:45 AM

Document Has Been Signed on 05/09/2023 09:57 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:KEEN HOME HARVARDFACILITY NUMBER:
306006299
ADMINISTRATOR:HERBAS, ADRIENFACILITY TYPE:
740
ADDRESS:5112 HARVARD AVETELEPHONE:
(562) 438-5336
CITY:WESTMINISTERSTATE: CAZIP CODE:
92683
CAPACITY: 6CENSUS: 0DATE:
05/09/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Adrien HerbasTIME COMPLETED:
10:10 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) Adrien Herbas, 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 01/12/2023. This is an initial application with no residents in care.

During the inspection, LPA and AP observed the following: Structure. This is a one-story home. Facility is a 6-bedroom, 5-bathroom, 1 story house with attached garage that is being used for storage and activities. There is a back yard with a patio cover for the residents. Facility telephone number is (714) 622-4062. Resident Bedrooms. The 6 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 108.5 and 110.8 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 will be stored in a lockable medication cart. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files. This is an initial inspection and LPA observed storage space for resident and staff files. Fire clearance was approved by Orange County Fire Authority on 02/08/23. Backyard. Backyard exit gate is operational and unlocked. Backyard has shaded area for outdoor activities and sufficient seating for residents. Component III was completed with AP during today’s inspection. AP will obtain liability insurance once the application is approved.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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: KEEN HOME HARVARD
FACILITY NUMBER: 306006299
VISIT DATE: 05/09/2023
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During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AP 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 AP.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC809 (FAS) - (06/04)
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