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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006414
Report Date: 03/04/2024
Date Signed: 03/04/2024 11:25:22 AM

Document Has Been Signed on 03/04/2024 11:25 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:DORSETT SENIOR MANORFACILITY NUMBER:
306006414
ADMINISTRATOR:ACASIO, ARMIN CLAIREFACILITY TYPE:
740
ADDRESS:8831 DORSETT DRTELEPHONE:
(214) 476-6864
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 6CENSUS: 4DATE:
03/04/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Armin Claire AcasioTIME COMPLETED:
12:00 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 was greeted and granted entry by Armin Claire Acasio, Applicant/Administrator.

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 residents was submitted to CCL on 09/11/2023.

Structure:
The facility is a one story house with an attached garage with 5 resident bedrooms, 1 staff bedroom, 2 full bathrooms, a living/dining room, and a kitchen. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with an exit walkway on both sides of the house with covered 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 4 private rooms and 1 shared room accommodating two residents. Bedrooms #6 has a full bathroom. Bedrooms Staff: Bedroom #4 designated for awake-staff. Bathrooms: All bathrooms have a working toilet, wash basin, walk in shower. Linens & Hygiene Supplies: Adequate supply of linen stored in bedroom hallway storage. 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

Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2024
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: DORSETT SENIOR MANOR
FACILITY NUMBER: 306006414
VISIT DATE: 03/04/2024
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for food serve for one week. Food Service: Adequate supply of 7-day non-perishable and 2-day perishables are stored in the kitchen and in garage. Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired, were tested and found operational. Appliances:
Gas four-burner stove, single oven, 2 refrigerators (kitchen & garage), microwave, 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 garage. Water Temperature: Tested and recorded maintained at a comfortable temperature and the water temperature measures 114.8 Fahrenheit degrees in facility bathrooms. Medications, First-Aid Kit & Book: Medication and first aid kit/book are stored and locked in a storage cabinet located staff bedroom. Resident & Staff Files: Records will be kept locked in medication cabinet. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the residents’ use, commensurate with the plan of operation. Fire clearance: Was approved on 9/21/2023. 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 with applicant 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: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024
LIC809 (FAS) - (06/04)
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