306006373-10-20-2023-22-AS-CGUZ-CWSU6X-20231020151902

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006373
Report Date: 10/20/2023
Date Signed: 10/20/2023 03:20:02 PM

Document Has Been Signed on 10/20/2023 03:20 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:	BARR SENIOR COURTYARD I		FACILITY NUMBER:	306006373
ADMINISTRATOR:	PONTOY,MARETIES		FACILITY TYPE:	740
ADDRESS:	8552 BARR LANE		TELEPHONE:	(626) 561-8029
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY: 6		CENSUS: 6	DATE:	10/20/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Mareties Pontoy		TIME COMPLETED:	03:30 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) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with designated Administrator (AD) Mareties Pontoy. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden residents was received by CCL on 7/05/2023. Structure: The facility is a one-story house with five resident bedrooms, four bathrooms, two storage rooms, one staff bedroom, living room, kitchen, dining room, office, and attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entranceway. There is a backyard that wraps around the house. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard. Resident Bedrooms All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets. LPA observed all windows were screened. Signal system There is no signal system. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked underneath the kitchen sink.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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: BARR SENIOR COURTYARD I	FACILITY NUMBER: 306006373
	VISIT DATE: 10/20/2023

NARRATIVE

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

Resident & Staff Files:
Records will be kept locked with medication.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
Fire extinguisher is fully charged.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, magazines and other recreational materials for the resident use, stored in the living room.

Fire clearance:
Was approved by a fire inspector of Orange County Fire Authority on 07/18/2023. No special conditions noted.

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

Bedrooms Staff:

There is one staff bedroom.

Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured between 105.0-108.3 degrees Fahrenheit.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: BARR SENIOR COURTYARD I	FACILITY NUMBER: 306006373
	VISIT DATE: 10/20/2023

NARRATIVE

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Linens & Hygiene Supplies:
A supply of extra linen was stored in the garage.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available, means of exiting, emergency phone numbers and food menu.

Food Service:
A supply of 2-day perishable and 7-day of non-perishable food will be maintained on hand and was observed during today’s visit.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas burner stove with oven, refrigerator, dish washer, microwave, washer, and dryer are operational.

Licensee to address the following:

· Fire clearance was approved for 6 non-ambulatory residents and one out of six residents currently in care is bedridden.

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: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

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