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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006306
Report Date: 01/18/2024
Date Signed: 01/18/2024 03:17:22 PM

Document Has Been Signed on 01/18/2024 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:CARE CHARLIZEFACILITY NUMBER:
306006306
ADMINISTRATOR:CALANGI, KARMIANFACILITY TYPE:
740
ADDRESS:17602 AMAGANSETTELEPHONE:
(949) 394-8708
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 6CENSUS: 6DATE:
01/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Karmian Calangi - AdministratorTIME COMPLETED:
03:32 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced inspection 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) Karmian Calangi. An application to operate a Residental Care Facility for the Elderly (RCFE) for (6) capacity, (2) ambulatory, (3) non-ambulatory, and (1) bedridden clients was received by Community Care Licensing (CCL) on 01/09/2023.

Structure: The facility is a one-story home with six resident bedrooms, two bathrooms, living room, kitchen, dining room, staff room, backyard and attached two car garage. There are two exit gates in the back yard. The backyard has a shaded seating area. LPA observed no obstacles in backyard.

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:Hot water measured at 110.6 degrees Fahrenheit in one of the common bathrooms and 107 degrees Fahrenheit in the other common bathroom.

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

Medications, First-Aid Kit & Files: Medication, first aid kit and files will be stored in a locked 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 purchased on 1/17/2024 as evidenced by the Home Depot receipt attached to the extinguishers.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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 2
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 CHARLIZE
FACILITY NUMBER: 306006306
VISIT DATE: 01/18/2024
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Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 8/23/2023.

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

Activity Materials: The facility contracts with a third party organizer that plans various outings for the residents. Residents go to parks, the movies, shopping, and more. Residents are also able to socialize with residents from other homes through this program.

Linens: A supply of extra linen is stored in the hallway 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: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
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