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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006375
Report Date: 11/30/2023
Date Signed: 11/30/2023 12:32:56 PM

Document Has Been Signed on 11/30/2023 12:32 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SYCAMORE CARE HOMESFACILITY NUMBER:
306006375
ADMINISTRATOR:ANG, ROSE ANNFACILITY TYPE:
740
ADDRESS:4704 AVENIDA DE LAS FLORESTELEPHONE:
(562) 275-2670
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 6CENSUS: 5DATE:
11/30/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:Emelyn Asis - Owner, Rose Ann Ang - AdministratorTIME COMPLETED:
12:45 PM
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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 and was greeted and granted entry by Owner Emelyn Asis and designated Administrator (AD) Rose Ann Ang. An application to operate a Residential Care Facility for the Elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden clients was received by Community Care Licensing (CCL) on 6/26/2023.

Structure: The facility is a one-story home with four resident bedrooms, two bathrooms, living room, kitchen, dining room, backyard, staff lounge and two car garage. There are two shaded seating areas in the backyard. There are two exit gates in the back yard. LPA observed no obstacles in back yard. LPA observed the ramp leading to the front door to make cracking sounds in some places. The ramp is still operable. Owner stated they will look into reinforcing or replacing the ramp.

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 under the kitchen sink.

Medications, First-Aid Kit & Files: Medication will be stored in a locked cabinet in the kitchen. The First Aid Kit had all the required elements and is stored with medication and facility records.

Fire Extinguisher: LPA observed the fire extinguisher to be fully charged and were purchased on 11/30/2023.

Component III: Information provided about how to operate the facility within compliance and reporting requirements.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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: SYCAMORE CARE HOMES
FACILITY NUMBER: 306006375
VISIT DATE: 11/30/2023
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Activity Materials: The facility has exercise equipment, books, puzzles, card/board games and art supplies.

Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 7/20/2023.

Bathrooms: The bathrooms have working plumbing. Hot water measured at 109.4 degrees Fahrenheit in the common bathroom and 110 degrees Fahrenheit in the bathroom in one of the shared rooms.

Linens and Hygiene Supplies: A supply of extra linen and hygiene supplies is stored in the hallway closet

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

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

Smoke Detectors: Smoke detectors and carbon monoxide detectors were tested and observed to be operational.

Appliances: Gas stove, oven, 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: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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