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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006400
Report Date: 11/22/2023
Date Signed: 11/22/2023 10:17:29 AM

Document Has Been Signed on 11/22/2023 10:17 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:MG HEIGHTS IFACILITY NUMBER:
306006400
ADMINISTRATOR:RICO, CAROLYNEFACILITY TYPE:
740
ADDRESS:10612 LEXINGTON STREETTELEPHONE:
(818) 572-3806
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY: 5CENSUS: DATE:
11/22/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Carolyne Rico - AdministratorTIME COMPLETED:
10:30 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 and was greeted by Carolyne Rico, Administrator and Ma Julia Chan, Licensee. An application to operate a Residential Care Facility for the Elderly (RCFE) for (5) capacity, (0) ambulatory, (4) non-ambulatory, and (1) bedridden clients was received by Community Care Licensing (CCL) on 8/4/2023.

Structure: The facility is a one-story home with three client bedrooms, two bathrooms, living room, kitchen, dining room, detached staff lounge, an attached two car garage and backyard. There is a door to the garage from a client room (bedroom 3). This door will only be used to enter the garage in emergencies. To protect the privacy, safety and personal rights of the resident that will reside in bedroom 3, this door will remain locked and the facility staff will use the outside entrance to the garage. There is a back yard with one exit gate on the side of the house. There are three stand-alone structures in the backyard. Two are sheds that will be used for storage. There is also a detached staff lounge with bathroom. Both storage sheds and staff lounge will remain locked to prevent resident access. There are two shaded seating areas on the covered patio in the backyard. LPA did not observe any obstacles or hazards in the backyard.

Client Bedrooms: All client bedrooms have the required furnishings. LPA observed all resident beds have linens and blankets. LPA observed all windows were screened.

Bathrooms: All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 120 degrees Fahrenheit in the bathroom accessible from the hallway and 119.8 degrees Fahrenheit in the bathroom accessible through bedroom 3. LPA advised staff to monitor temperatures.

Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and are stored and locked in cabinets in the kitchen and garage.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2023
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: MG HEIGHTS I
FACILITY NUMBER: 306006400
VISIT DATE: 11/22/2023
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Linens & Hygiene Supplies: A supply of extra linen and hygiene are stored in a closet in the hallway and garage.

Medication, First Aid Kit and Files: Medication will be locked in cabinet in dining area. First Aid Kit is in a cabinet in the garage and files will be stored in a cabinet in the living room.

Activity Materials: The facility has board games stored in the living room.

Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 8/30/2023.

Smoke/CO2 Detectors & Fire Extinguisher: Dual smoke/CO2 detectors were tested and observed to be operational and connected. LPA observed the fire extinguisher to be fully charged with receipt indicating it was purchased on 8/29/2023.

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

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

Component III: Presentation was reviewed and provided to the applicant. Information about operating the facility in compliance was reviewed.

Appliances: Gas five burner 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: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023
LIC809 (FAS) - (06/04)
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