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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006430
Report Date: 05/28/2024
Date Signed: 05/28/2024 12:42:23 PM

Document Has Been Signed on 05/28/2024 12:42 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ANKERTON SUITEFACILITY NUMBER:
306006430
ADMINISTRATOR/
DIRECTOR:		LINGAT, TRISTANFACILITY TYPE:
740
ADDRESS:24192 ANKERTON DRIVETELEPHONE:
(949) 374-2683
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 3DATE:
05/28/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:59 AM
MET WITH:Tristan LingatTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Joseph Alejandre conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA met with Tristan LIngat and toured the facility.

An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to CCL on October 2, 2023. The facility is to have a capacity of 6 nonambulatory, of which 1 can be bedridden (room 5 is the only designated bedridden room). Applicant has requested a hospice waiver for 6 residents. Facility phone number 949-328-9314. LPA observed the following.

Structure:
The facility is a one story house with an attached 2 car garage with 6 bedrooms, 3 bathrooms, dining room, a kitchen and a great room. There are 7 exits, one exit in each bedroom and the front door. There are no fireplaces.

Air/Heating:
Central air/heating system installed with a central panel to control entire house.

Resident Bedrooms:
There are 6 Resident Bedrooms and each bedroom is private. The bedrooms are spacious and will easily accommodate the residents' belongings. All resident rooms had the required furnishings.

Bedrooms Staff:
There are no staff bedrooms.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2024
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 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: ANKERTON SUITE
FACILITY NUMBER: 306006430
VISIT DATE: 05/28/2024
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Bathrooms:
All bathrooms have a working toilet, wash basin and walk in shower. All bathrooms are clean and operational.

Linens & Hygiene Supplies:
Adequate supply of linen stored in bedrooms.

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 for food served for one week.

Food Service:
There is a 2-day perishable and a 7-day non-perishable food supply on hand in the ktichen.

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors/carbon monoxide detectors tested operational. The fire extinguisher in the dining room is fully charged.

Appliances:
There is one 5 gas burner stove which lights unassisted, 1 oven, 1 microwave, a refrigerator, dishwasher, washer, and dryer. All appliances are clean and operational.

Toxins:
All cleaning supplies and chemicals are stored in the garage.

Water Temperature:
Hot water was measured in all bathrooms. Hot water measured between 113.1 to 114.6 degrees Fahrenheit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
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: ANKERTON SUITE
FACILITY NUMBER: 306006430
VISIT DATE: 05/28/2024
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Medications, First-Aid Kit & Book:
The first aid kit is mounted on the dining room wall. The first aid book is kept on the dining room cabinet. The first aid kit has all the required elements. Medications will be stored in the cabinet in the dining room. The cabinet is kept locked.

Resident & Staff Files:
The Resident and Staff Records will be kept locked in the cabinet in the dining room.

Reading Material, Games, Equipment & Materials:
Games and reading material, are stored in the dining room cabinet. There is a large screen TV mounted in the great room.

Garage: The garage is used for storage The chemicals, cleaning supplies and dangerous items are kept locked in cabinets in the garage.

Backyard: The backyard has two shaded seating areas with tables and chairs. No bodies of water observed. There are two sheds in the backyard. Both sheds are kept locked and used for storage. The exit gate is latched and self closing. No obstacles or hazards observed in the backyard.

Fire clearance:
Fire Clearance approved by Orange County Fire Authority Inspector Kevin Chaney on October 17, 2023.

Component III:
Component three was completed with the applicant.

The applicant has met all pre-licensing requirements. The facility is ready to be licensed. LPA will submit notification to CAB (Central Applications Bureau) in Sacramento for final review prior to license being issued. Applicant was informed today that the final approval will be processed/granted by CAB in Sacramento.

An exit interview was conducted and a copy of this report was left with the applicant.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC809 (FAS) - (06/04)
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