306006406-8-6-2024-22-AS-JCHO-D7VPDS-20240806111402

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006406
Report Date: 08/06/2024
Date Signed: 08/06/2024 11:14:14 AM

Document Has Been Signed on 08/06/2024 11:14 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	HILLS OF BROADWAY, THE		FACILITY NUMBER:	306006406
ADMINISTRATOR/ DIRECTOR:	MIRANDA, ROSENDO CARLO		FACILITY TYPE:	740
ADDRESS:	354 BROADWAY		TELEPHONE:	(714) 430-7672
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY: 6		CENSUS: 6	DATE:	08/06/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	07:00 AM
MET WITH:	Maricel Nepo Muceno- Applicant Rosendo Miranda-Administrator Brian Mahinay- Quality Assurance Specialist		TIME VISIT/ INSPECTION COMPLETED:	11:35 AM

NARRATIVE

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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility announced for the purpose of conducting a Pre-Licensing visit for a change of ownership using the Care Inspection Tool. LPA conducted the visit with Applicant Maricel Nepo, Administrator Rosendo Miranda and Quality Assurance Specialist (QAS) Brian Mahinay. An initial application to operate a Residential Care Facility for the Elderly (RCFE), age range 60 and over, for (0) ambulatory, (6) non-ambulatory, and (0) bedridden residents was received by the Department of Social Services on August 28, 2023.

LPA toured the interior and exterior portion of the facility and observed the following accompanied by the Applicant , Administrator, QAS:

Structure:

The facility is a single story residential property comprised of six resident bedrooms, five resident bathrooms with full baths, a living room, dining area, kitchen, storage room, an attached laundry room/two car garage, and a backyard. There is a private home behind the facility on the same lot with a private entry that will be occupied by the Administrator. The address is 354 Unit B Broadway, Costa Mesa, CA 92626. The backyard has two exit gates on one side of the property. There is a shaded seating area. LPA did not observe any obstacles or hazards in the backyard. One door inside the house is delayed egress and approved via fire clearance.

Signal System:
The facility utilizes a signal system where staff is alerted from a central location (kitchen).

Bedrooms:
The resident bedrooms had all required components, are spacious, and easily accommodates the residents’ furnishings.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

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 BROADWAY, THE	FACILITY NUMBER: 306006406
	VISIT DATE: 08/06/2024

NARRATIVE

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Bathrooms:
Bathrooms were not clean. Grab bars were secure.

Linens and Hygiene Supplies:
Clean linens were observed to be fully stocked.

Appliances:
Stove burners, microwaves, washers, and dryers were inspected and operable. Appliances require a deep cleaning.

Resident and Staff Files:
Resident and staff records will be maintained on site.

Reading Material, Games, Equipment, & Materials:
The facility maintains reading material and games in the facility.

Emergency Phone Numbers/Exit Plan:
Posted in the entry way area and available for review.

Postings:
The See Something, Say Something (PUB475) and the Ombudsman Posters were posted in the entry area of the facility. The Rights of the Resident Councils, Resident's Rights, Theft & Loss Policy, Activity Schedule, and Admission Agreement were posted and is accessible in the state folder in the entry way.

Food Service and Menu:
Supply of seven day non-perishable and two day perishables were observed. The sample menu was available for review. The emergency food/water supply was stored in the garage.

Smoke and Carbon Monoxide Detectors:
The dual purpose smoke detector and carbon monoxide alert systems were tested and found to be operational.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

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 BROADWAY, THE	FACILITY NUMBER: 306006406
	VISIT DATE: 08/06/2024

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Fire Extinguishers:
Two fire extinguishers were mounted, fully charged, and serviced on October 4, 2023.

Fire Clearance:
Approved on July 10, 2024 for 6 non-ambulatory residents.

Toxins and Sharps:
Cleaning supplies, toxins, and sharps were secured and inaccessible.

Water Temperature:
The water temperature in the resident bathrooms measured at 111.7, 113.7, 114.0, 111.9, and 110.1 degrees Fahrenheit.

Medications, First Aid Kit & Manual:
The First Aid Kit was checked and found to be in order. The facility has the current edition of the First Aid Manual.

Component III:
Component III is waived due to the applicant operating licensed facilities and having completed Component III previously.

The following items need correction prior to licensure:

To deep clean the kitchen appliances, inside the refrigerator/freezer, kitchen drawers/pantries, entire floor, and all bathrooms including showers.
To treat stains/spots on furniture.
To organize and remove clutter in the garage.
To repair the leak from the garage refrigerator, install a missing drawer handle in the kitchen drawer, holes in the hallway(s)
To spot treat/paint the walls, doors, and kitchen cabinetry

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

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

FACILITY NAME: HILLS OF BROADWAY, THE	FACILITY NUMBER: 306006406
	VISIT DATE: 08/06/2024

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 26 27 28 29 30 31 32	Facility does not appear ready for licensure. Any items noted above during today’s visit are to be corrected by An exit interview was conducted with Applicant Joanne Casten, and a copy of this report was provided at the end of the visit.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

LIC809 (FAS) - (06/04)

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