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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006423
Report Date: 03/08/2024
Date Signed: 03/08/2024 09:22:09 AM

Document Has Been Signed on 03/08/2024 09:22 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
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:
03/08/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Kevin DinhTIME COMPLETED:
09:35 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection to follow up on corrections identified during visit on 2/01/2024. LPA met with Licensee Kevin Dinh and Dennis 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.

At 8:40 a.m. LPA toured the facility and observed the following:

· Water temperature tested between 111.9-113.9 degrees F in two out of two bathrooms.

· Facility has a shaded seating area in the backyard and backyard is free of obstacles and hazards.

· Hand soap is available in residents’ bathroom.

· Facility has battery powered flashlight readily accessible to residents and staff.

· Facility has clean linen, including blankets and bedspreads and an extra supply in the hallway storage.

· All outdoor and indoor passageways are free of obstruction.

· “Rights of Resident Councils” is posted in a prominent place at the facility accessible to residents, family members, and resident representatives.

Component III: was conducted during this inspection, information provided about how to operate the facility within compliance and reporting requirements.

The facility is ready to be licensed. The Licensee was notified that the final application approval will be issued by the Centralized Applications Bureau (CAB) in Sacramento. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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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