<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006423
Report Date: 02/01/2024
Date Signed: 02/01/2024 03:39:56 PM

Document Has Been Signed on 02/01/2024 03:39 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SYRACUSE RESIDENTIAL CAREFACILITY NUMBER:
306006423
ADMINISTRATOR:BUI, ANDREFACILITY TYPE:
740
ADDRESS:7362 SYRACUSE AVETELEPHONE:
(669) 216-8500
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY: 6CENSUS: 0DATE:
02/01/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Andre BuiTIME COMPLETED:
03:50 PM
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
Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with designated Administrator (AD) Andre Bui. An application to operate Residential Care Facility for the Elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden residents was received by CCL on 9/18/2023.

Structure:
The facility is a one-story house with three client bedrooms, two bathrooms, living room, kitchen, laundry room, and attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall in the entranceway. There is a backyard with an exit gate each side of the house. There is no shaded seating area and LPA observed obstacles and hazards in the backyard, including: a jagged edged gardening tool, a trash can laying on its side, a discarded cleaning brush and toothbrush, a picketed white wood door missing a picket leaning against a brick wall, and overgrown grass and weeds.

Resident Bedrooms
All client bedrooms had the required furnishings. Beds were observed to have linens, however, did not have blankets or comforters.

Signal system
There is no signal system.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked underneath the kitchen sink and in the laundry room.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SYRACUSE RESIDENTIAL CARE
FACILITY NUMBER: 306006423
VISIT DATE: 02/01/2024
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
Medications, First-Aid Kit & Book:
Medication will be stored in a locked closet. First aid kit is stored with medication. The first aid kit has all the required elements.

Resident & Staff Files:
Records will be kept with medication in a locked closet.

Pool/Jacuzzi:
Swimming pool in the backyard was observed to be fenced as required by regulations.

Fire Extinguisher:

Fire extinguisher is fully charged.

Reading Material, Games, Equipment & Materials:


The facility currently does not have reading material, games, or any other recreational material for resident use.

Fire clearance:
Was approved by a fire inspector of Orange County Fire Authority on 12/07/2023. Special conditions noted, “Room 1 approved for 2 non-ambulatory. Room 2 approved for 2 non-ambulatory. Room 3 approved for 1 non-ambulatory and 1 bedridden.”

Bedrooms Staff:
There is no staff bedroom.

Bathrooms:
All bathrooms have working plumbing. Hot water measured at 134.4 degrees Fahrenheit.

Linens & Hygiene Supplies:
Facility currently does not have a supply of extra linen.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SYRACUSE RESIDENTIAL CARE
FACILITY NUMBER: 306006423
VISIT DATE: 02/01/2024
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
Emergency Phone Numbers, Exit Plan & Menu:
Posted and available, means of exiting, and emergency phone numbers. Food menu was available for review and will be posted.

Food Service:
A supply of 2-day perishable and 7-day of non-perishable food will be maintained on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas five burner stove with oven, refrigerator, microwave, washer, and dryer are operational.

Licensee to address the following corrections by 02/16/2024:

  • Water temperatures tested at 134.4 degrees F in residents’ bathroom. Water temperature to be adjusted to meet regulation of 105 to 120 degrees F.
  • Facility does not have a shaded seating or furnished area in any of its outdoor spaces. Outdoor areas shall be equipped for outdoor use and free of obstacles and hazards.
  • Hand soap was not available in residents’ bathroom. Hygiene supplies must be provided.
  • Emergency lighting shall be maintained. At a minimum this shall include flashlights, or other battery powered lighting, readily accessible to residents and staff.
  • Clean linen shall be provided, including blankets, bedspreads, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week.
  • All outdoor and indoor passageways and stairways shall be kept free of obstruction.
  • “Rights of Resident Councils” shall be posted in a prominent place at the facility accessible to residents, family members, and resident representatives.

LPA will make an additional announced visit to follow-up on corrections listed above. An exit interview was conducted, and a copy of this report was provided to designated AD.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3