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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006397
Report Date: 02/29/2024
Date Signed: 02/29/2024 03:17:00 PM

Document Has Been Signed on 02/29/2024 03:17 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ARISE HOMES 2FACILITY NUMBER:
306006397
ADMINISTRATOR:CARRILLO, ROWENA MARANTALFACILITY TYPE:
740
ADDRESS:23232 LA VACA ST.TELEPHONE:
(949) 446-4584
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 2DATE:
02/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rowena CarilloTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at the facility and was greeted and granted entry. LPA met with Rowena Carrillo, Applicant/Administrator and explained the visit.

A change of ownership application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden resident was submitted to CCL on 08/03/23.

Structure:
The facility is a one-story house with an attached garage with 6 resident bedrooms, 3 full bathrooms, a living room, a dining room, and a kitchen. The residents’ bedrooms are spacious and will easily accommodate the residents’ furnishings. There is a large back yard with a closed patio and one exit walkway on one side of the house with seating for the residents.

Air/Heating:
Central air/heating system installed with a central panel to control entire house. Bedrooms Residents:
Bedrooms will accommodate 6 residents with 6 private rooms. Bedroom 6 has a full bathroom. Bedrooms Staff: No bedroom designated for wake staff. Bathrooms: The facility has three full bathrooms. All bathrooms have a working toilet, wash basin, and walk-in shower. Linens & Hygiene Supplies: Adequate supply of linen in closet storage in main living room. 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: Adequate supply of 7-day non-perishable and 2-day perishables are stored in the

Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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: ARISE HOMES 2
FACILITY NUMBER: 306006397
VISIT DATE: 02/29/2024
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kitchen. Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired, tested, and found operational. Fire extinguishers mounted/charged in bedroom hallways. Appliances: Gas six burner stove, single oven, refrigerator, microwave, dishwasher, washer, and dryer are clean and noted to be operational. Toxins: All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents and are stored and locked in cabinets in laundry unit. Water Temperature: Tested and recorded maintained at a comfortable temperature and the water temperature measures 113 Fahrenheit degrees in facility bathrooms. Medications, First-Aid Kit & Book: Medication and First Aid kit stored in locked storage cabinet in kitchen. Resident & Staff Files: Records will be kept locked in a storage cabinet in the kitchen. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the resident's use, commensurate with the plan of operation. Fire clearance: Was approved on 09/26/23. Component III: Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities.

The applicant has met all pre-licensing requirements. LPA will submit notification to CAB in Sacramento for final review prior to license being issued.

Exit interview was conducted and a copy of this report was left with the applicant.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC809 (FAS) - (06/04)
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