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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006342
Report Date: 09/05/2023
Date Signed: 09/05/2023 11:15:01 AM

Document Has Been Signed on 09/05/2023 11:15 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MARIGOLD BOARD AND CAREFACILITY NUMBER:
306006342
ADMINISTRATOR:KAUR, UKARJITFACILITY TYPE:
740
ADDRESS:8601 SAN ROMOLO WAYTELEPHONE:
(661) 236-6787
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: DATE:
09/05/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Ukarjit Kaur - AdministratorTIME COMPLETED:
11:30 AM
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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. LPA arrived at the facility at 8:30 am and was greeted and granted entry by designated Administrator (AD) Ukarjit Kaur and Licensee Celena Jen Sherman. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden clients was received by Community Care Licensing (CCL) on 4/10/2023.

Structure:
The facility is a one-story home with three resident bedrooms, two resident bathrooms, one staff room, living room, kitchen, dining room, an attached two car garage and backyard. All doors leading to the backyard are equipped with alarms to notify staff when they are opened. AD notified LPA that the 20” x 26” PUB 475 See Something, Say Something Poster had been ordered. There is a back yard with one exit gate. The facility has a shaded area and AD showed proof of purchase of outdoor facility furniture. LPA did not observe any obstacles or hazards in the 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.

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

Medications, First-Aid Kit & Book: Medication and First Aid Kit will be stored in a locked cabinet in the kitchen. The first aid kit has all the required elements.

Resident & Staff Files: Records will be kept in a cabinet in the dining room.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023
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: MARIGOLD BOARD AND CARE
FACILITY NUMBER: 306006342
VISIT DATE: 09/05/2023
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Fire Extinguisher: LPA observed one fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone. LPA observed the service tag on the fire extinguisher which indicates the fire extinguisher was last serviced on 3/14/23.

Reading Material, Games, Equipment & Materials: The facility has books and games in the entryway closet.

Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 05/23/2023.

Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Bathrooms: The bathrooms have working plumbing. Hot water measured at 113 degrees Fahrenheit in Bathroom 1 and 116.2 degrees Fahrenheit in Bathroom 2.

Linens & Hygiene Supplies: A supply of extra linen is stored in the entryway closet. Hygiene supplies are stored in the garage

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

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

Smoke Detectors: Carbon Monoxide Detector is not connected to the smoke detectors. Smoke detectors are connected throughout the home. Both types of detectors were tested and observed to be operational.

Appliances: Gas four burner stove with 1 oven, 1 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: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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