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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006438
Report Date: 05/03/2024
Date Signed: 05/03/2024 10:47:16 AM

Document Has Been Signed on 05/03/2024 10:47 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:DALTON RESIDENTIAL CAREFACILITY NUMBER:
306006438
ADMINISTRATOR/
DIRECTOR:		BUI, DENNISFACILITY TYPE:
740
ADDRESS:9772 WILLIAM DALTON WAYTELEPHONE:
(714) 300-4540
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6CENSUS: DATE:
05/03/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Kevin Dinh-Licensee, Dennis Bui-AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:01 AM
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 Analysts (LPA) Alvaro Ramirez, Jr. conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA met with Applicant Kevin Dinh and toured the facility.

An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to Community Care Licensing (CCL) on October 01, 2023. The facility is to have a capacity of 6, of which 5 can be nonambulatory and 1 bedridden. Facility phone number 714-300-4540. LPA observed the following.

Structure:
The facility is a one-story house with four resident bedrooms, two full size bathrooms, a living room, a kitchen, a dining room, and an attached car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entranceway. There is a backyard with an exit gate on each side of the house. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard.

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

Resident Bedrooms:
There are four Resident bedrooms. All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets.


CONTINUED ON LIC809-C...
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: DALTON RESIDENTIAL CARE
FACILITY NUMBER: 306006438
VISIT DATE: 05/03/2024
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
Bathrooms:
All bathrooms are clean and have working plumbing. Hot water measured between 106.1 and 109.7 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in the closet of each resident bedroom.

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. Monthly menu available and posted in the kitchen refrigerator.

Food Service:
There are no residents living in the facility at this time. There is 7-day non-perishable food supply on hand.

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors/carbon monoxide detectors are hardwired and tested operational. There is a fire extinguisher mounted on the wall by the dining room.

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

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored in the garage.

Water Temperature:
Hot water was measured in all bathrooms. Hot water measured between 106.1 and 109.7 degrees Fahrenheit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: DALTON RESIDENTIAL CARE
FACILITY NUMBER: 306006438
VISIT DATE: 05/03/2024
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:
The first aid kit and the first aid manual are stored in the closet next to the kitchen. The first aid kit has all the required elements. Medications will be stored in locked cabinet next to kitchen.

Resident & Staff Files:
The Resident and Staff Records will be kept in a locked cabinet next to the kitchen.

Reading Material, Games, Equipment & Materials:
Arts and craft, board games and movies are stored in the living room cabinet. There is one large screen television mounted in the living room and one in the dining room.

Fire clearance:
Fire Clearance approved by a fire inspector of Orange County Fire Authority on 12/12/23. Special conditions noted, "Bedrooms 1,2 and 4 Approved for Nonambulatory" and "Bedroom 3 approved for Bedridden and Nonambulatory"

Component III:
Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities.

Applicant was reminded that it is required to notify LPA when admitting their first resident. This notification may be done by phone, email or fax.

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

Exit interview was conducted and a copy of this report was left with the applicant.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3