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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006474
Report Date: 04/10/2024
Date Signed: 04/10/2024 04:59:16 PM

Document Has Been Signed on 04/10/2024 04:59 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:VILLA SOCORROFACILITY NUMBER:
306006474
ADMINISTRATOR/
DIRECTOR:		ATENCIO, CLEMENCIAFACILITY TYPE:
740
ADDRESS:11861 MARTHA ANN DRIVETELEPHONE:
(310) 953-5518
CITY:LOS ALAMITOSSTATE: CAZIP CODE:
90720
CAPACITY: 6CENSUS: DATE:
04/10/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
04:59 PM
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Licensing Program Analysts (LPAs) Joseph Alejandre and Edward Kim conducted an announced visit to the facility to conduct the pre-licensing inspection. LPAs met with Applicant Christina Atencio and toured the facility.

An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to CCL on December 18, 2023. The facility is to have a capacity of 6, of which 5 can be nonambulatory and 1 bedridden. Applicant has requested a hospice waiver for 6 residents. Facility phone number 424-271-9350. LPAs observed the following.

Structure:
The facility is a one story house with an attached 2 car garage with 7 bedrooms (1 is for staff), 7 full bathrooms, 1 half bathroom with no shower, 1 office (no closet), dining room, a kitchen and living room with a screened fireplace. There are 4 exits, one exit door in the kitchen, one in the hallway outside of bedroom 7, the front door and the exit in bedroom 1 which is approved for 1 bedridden resident.

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:
Bedroom 5 is designated as the staff bedroom.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024
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: VILLA SOCORRO
FACILITY NUMBER: 306006474
VISIT DATE: 04/10/2024
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Bathrooms:
All bathrooms have a working toilet, wash basin and walk in shower, except for bathroom 8 which has no 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 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 are fire extinguishers mounted on the wall in the kitchen, next to garage entrance, and one next to the resident hallway. All 3 fire extinguishers are fully charged.

Appliances:
There is one 4 gas burner stove which lights unassisted, 1 oven, microwave oven mounted above the stove, a refrigerator, dishwasher, washer, and dryer. All appliances are clean and operational.

Toxins:
All cleaning supplies and chemicals are kept in two areas: kitchen cleaning supplies locked under the ktichen sink and all extra cleaning supplies are locked in the garage..

Water Temperature:
Hot water was measured in all bathrooms. Hot water measured between 115.8 to 117.6 degrees Fahrenheit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
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: VILLA SOCORRO
FACILITY NUMBER: 306006474
VISIT DATE: 04/10/2024
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Medications, First-Aid Kit & Book:
The first aid kit and the first aid manual are stored in pantry next to the dining room. The first aid kit has all the required elements. Medications will be stored in the pantry next to the dining room. The pantry is kept locked.

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

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

Fire clearance:
Fire Clearance approved by Orange County Fire Authority Inspector Anthony Vasily on March 21, 2024.

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: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC809 (FAS) - (06/04)
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