306006368-4-19-2024-22-AS-JALE-D4GVPX-20240419163728

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006368
Report Date: 04/19/2024
Date Signed: 04/19/2024 04:37:46 PM

Document Has Been Signed on 04/19/2024 04:37 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	HILLS OF ORCHID, THE		FACILITY NUMBER:	306006368
ADMINISTRATOR/ DIRECTOR:	NEPOMUCENO, MARICEL		FACILITY TYPE:	740
ADDRESS:	20271 ORCHID STREET		TELEPHONE:	(714) 430-7672
CITY:	NEWPORT BEACH	STATE: CA	ZIP CODE:	92660
CAPACITY: 6		CENSUS: 5	DATE:	04/19/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:45 PM
MET WITH:	Maricel Nepomuceno,Rosendo Carlo Miranda		TIME VISIT/ INSPECTION COMPLETED:	04:55 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 Analyst (LPA) Joseph Alejandre made an announced visit to conduct the pre-licensing inspection. LPA met with applicant Maricel Nepomuceno and Administrator Rosendo Carlo Miranda An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to CCL on August 29, 2023. The facility is to have a capacity of 6, of which 6 can be nonambulatory and zero bedridden. Applicant has requested a hospice waiver for 6 residents. Facility phone number 949-490-4062. This is a change of ownership. There are 5 residents in care at the facility. LPA observed the following. Structure: The facility is a two story house with an attached 2 car garage with 6 bedrooms (1 is for staff, upstairs), 6 bathrooms, 1 dining room, a kitchen and living room. There are 7 exits, one exit door in each downstairs bedroom, the front door, and an exit door in the main hallway by the staircase. The facility is a two-story home. LPA did not observe an evacuation chair mounted next to the top of the stairway. Air/Heating: The facility has a central heating system. Each resident room has it's own air conditioner. Resident Bedrooms: There are 5 Resident Bedrooms. Room number 2 is a shared room. The bedrooms are spacious and will easily accommodate the residents' belongings. All resident rooms had the required furnishings. Bedrooms Staff: The second floor bedroom is the designated staff bedroom.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HILLS OF ORCHID, THE	FACILITY NUMBER: 306006368
	VISIT DATE: 04/19/2024

NARRATIVE

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Bathrooms:
All 6 bathrooms are clean and operational.

Linens & Hygiene Supplies:
Adequate supply of linen stored in the hallway cabinet.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food served for one week.

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

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors/carbon monoxide detectors tested operational. There are 3 fire extinguishers in the facility. 1 is mounted on the wall next to the kitchen. 1 is in the garage and one is in the hallway next to the stairway.

Appliances:
There is one 4 gas burner stove which lights unassisted, 1 oven, microwave oven on the kitchen counter, a refrigerator, dishwasher, washer, and dryer. All appliances are clean and operational.

Toxins:
All cleaning supplies and chemicals are kept in two areas: kitchen cleaning supplies locked under the kitchen sink and all extra cleaning supplies are locked in the garage. The garage is kept locked and used for storage.

Water Temperature:
Hot water was measured in all bathrooms. Hot water measured between 109.4 to 113.7 degrees Fahrenheit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HILLS OF ORCHID, THE	FACILITY NUMBER: 306006368
	VISIT DATE: 04/19/2024

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Medications, First-Aid Kit & Book:
The first aid kit and the first aid manual are stored in the hallway cabinet next to the stairway. The first aid kit has all the required elements. Medications are kept locked in the hallway cabinet next to the stairway.

Resident & Staff Files:
The Resident and Staff Records are kept locked in the cabinet in the hallway next to the stairs.

Reading Material, Games, Equipment & Materials:
Arts and craft, tablet, and board games are stored in the hallway next to the stairs and in the living room. There is a large screen TV mounted in the living room.

Fire clearance:
Fire clearance was approved on March 19, 2024 by Newport Beach Fire Department fire inspector Nadine Morris.

Backyard:
LPA observed there is a shaded seating area with a table, 4 chairs and an umbrella. There is a storage building in the backyard that is kept locked. LPA observed old furniture and wheelchairs in the storage building. No obstacles or hazards observed in the backyard. Both exit gates are latched and self-closing. Each exit gate has a working auditory alarm that sounds when the gates are opened.

Component III:
Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities.

The facility is not ready to be licensed. The Applicant was informed to contact the LPA to schedule the next pre-licensing inspection when the evacuation chair has been installed. Applicant was informed today that the final approval will be processed by CAB (Central Applications Bureau) in Sacramento.

Exit interview was conducted and a copy of this report was left with the applicant.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

LIC809 (FAS) - (06/04)

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