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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006304
Report Date: 12/12/2023
Date Signed: 12/12/2023 03:35:37 PM

Document Has Been Signed on 12/12/2023 03:35 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:CARE PHOEBEFACILITY NUMBER:
306006304
ADMINISTRATOR:PAO, ADRIELFACILITY TYPE:
740
ADDRESS:14661 BROOKLINE WAYTELEPHONE:
(714) 368-4627
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 6CENSUS: 5DATE:
12/12/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Adriel Pao - AdministratorTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced visit to the facility for purpose of conducting a pre-licensing inspection for a change of ownership. LPA arrived at the facility and was greeted and granted entry by designated Administrator (AD) Adriel Pao. An application to operate a Residential Care Facility for the Elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden clients was received by Community Care Licensing (CCL) on 1/20/2023.

Structure: The facility is a one-story home with five resident bedrooms, two bathrooms, living room, kitchen, dining room, staff room, laundry area, backyard and attached two car garage. There are two exit gates in the back yard. The backyard has a seating area. The garage has two additions for storage. These additions are not accessible to residents in care.

Client Bedrooms: All resident bedrooms had the necessary furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened.

Bathrooms: The bathrooms have working plumbing. Hot water measured at 116.2 degrees Fahrenheit in the bathroom closest to the entrance and 116.9 degrees Fahrenheit in the bathroom toward the back of the house.

Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored under the kitchen sink and in cabinets above laundry machines.

Medications, First-Aid Kit & Files: Medication will be stored in a locked cabinet in the dining room. The First Aid Kit will be stored on table in entryway. Records will be kept in a cabinet in the hallway.

Fire Extinguisher: LPA observed the fire extinguishers to be fully charged as indicated by the arrow pointing in the green zone. Extinguishers were serviced on 3/1/2023
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023
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: CARE PHOEBE
FACILITY NUMBER: 306006304
VISIT DATE: 12/12/2023
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Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 5/22/2023.

Component III: Information provided about how to operate the facility within compliance and reporting requirements.

Activity Materials: Facility has a full activity calendar including but not limited to: karaoke, zumba, bingo, family time, movie days, exercise and more.

Linens: A supply of extra linen is stored in the entryway closet

Emergency Phone Numbers, Exit Plan and Menu: Posted and available for review.

Food Service: There is 2-day supply of perishable food and a 7-day supply of non-perishable food on hand.

Smoke Detectors: Smoke detectors and carbon monoxide detectors were tested and observed to be operational.

Appliances: Gas stove, oven, refrigerator, dish washer, microwave, washer, and dryer are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. 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: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC809 (FAS) - (06/04)
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