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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006336
Report Date: 09/13/2023
Date Signed: 09/13/2023 12:17:53 PM

Document Has Been Signed on 09/13/2023 12:17 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:KRISNELLE HOME CAREFACILITY NUMBER:
306006336
ADMINISTRATOR:JESSICA VILLANUEVAFACILITY TYPE:
740
ADDRESS:9232 MARCHAND AVENUETELEPHONE:
(714) 267-4548
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6CENSUS: 5DATE:
09/13/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessica VillanuevaTIME COMPLETED:
12:30 PM
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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) Jessica Villanueva, 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 03/20/2023. This is a change of ownership with persons in care.

During the inspection, LPA and AP observed the following: Structure: facility is a 4-bedroom, 2-bathroom, 1-story house with an attached garage that is being used for storage. Facility telephone number is (714) 537-6870. Resident Bedrooms: the 3 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Lights, chairs, linens, and storage for each resident bedroom inspected. Staff Bedrooms: the 1 staff bedroom is spacious and will easily accommodate the staff’s furnishings. Bathrooms: were clean, faucets and toilets were operational. Water temperature: tested at 108.1 degrees F in the common bathroom and 106.8 in the private bathroom. 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: 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 shed. Medication cabinet is locked. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files: LPA reviewed 2 resident files and 2 staff files. Fire clearance was approved by Orange County Fire Authority on 06/26/2023. 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. Facility is currently operating under the liability insurance of current facility SHINING BRIGHT SENIOR CARE HOME (306005306). AP will switch liability insurance to new facility once the application is approved.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2023
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: KRISNELLE HOME CARE
FACILITY NUMBER: 306006336
VISIT DATE: 09/13/2023
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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: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC809 (FAS) - (06/04)
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