306006322-5-22-2023-22-AS-SHAD-CS3S97-20230522134015

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006322
Report Date: 05/22/2023
Date Signed: 05/22/2023 01:40:18 PM

Document Has Been Signed on 05/22/2023 01:40 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	PRIME VILLA SKYE		FACILITY NUMBER:	306006322
ADMINISTRATOR:	ATENCIO JOHN PAUL		FACILITY TYPE:	740
ADDRESS:	3305 DRUID LN		TELEPHONE:	(310) 634-4419
CITY:	ROSSMOOR	STATE: CA	ZIP CODE:	90720
CAPACITY: 6		CENSUS: 0	DATE:	05/22/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	John Paul Atencio		TIME COMPLETED:	01:55 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 Analysts (LPAs) Dwayne Mason Jr. and Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPAs met with Applicant (AP) John Paul Atencio, 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 02/21/2023. This is an initial application with no residents in care. During the inspection, LPAs and AP observed the following: Structure. This is a one-story home. Facility is a 4-bedroom, 4-bathroom, 1 story house with a detached building in the backyard that is being used for storage. There is a back yard with a patio cover for the residents. Facility telephone number is (562) 330-5789. Resident Bedrooms. The 4 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 106.7 and 116.7 F degrees. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. 7 days nonperishable food supply reviewed and AP stated they will obtain 2 days perishable food supply prior to accepting residents. 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 cleaning closet. Medication closet is locked. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files. This is an initial inspection and LPAs observed storage space for resident and staff files. Fire clearance was approved by Orange County Fire Authority on 03/23/23. 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: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

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: PRIME VILLA SKYE	FACILITY NUMBER: 306006322
	VISIT DATE: 05/22/2023

NARRATIVE

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During the inspection, LPAs and AP observed a detached building in the backyard which is identified as “ADU Not part of the care facility” on the facility sketch. LPAs inspected this building, observed it to contain a main room, kitchen, and bathroom, confirmed there were no beds inside, that no person was living in the building, and that the building is being used for storage. LPAs took photographs of the interior and exterior of the building. LPAs had a conversation with AP about the building and AP understands that the building is to be used only for storage, that the building cannot contain any beds, and that no persons may sleep there. LPAs advised AP on the steps to have the building fire cleared as a staff bedroom should AP choose to do so in the future. AP stated they understand that no one may sleep in or live in the building unless it is fire cleared as a bedroom. LPAs had AP sign a declaration confirming these facts.

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: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

LIC809 (FAS) - (06/04)

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