306006480-8-13-2024-22-AS-EKIM-D84UUF-20240813155329

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006480
Report Date: 08/13/2024
Date Signed: 08/13/2024 03:53:39 PM

Document Has Been Signed on 08/13/2024 03:53 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:	AMARI HOUSE		FACILITY NUMBER:	306006480
ADMINISTRATOR/ DIRECTOR:	MOSHARRAF, MUSHAIRA		FACILITY TYPE:	740
ADDRESS:	515 N HARCOURT ST		TELEPHONE:	(562) 377-4764
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY: 6		CENSUS: 0	DATE:	08/13/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Mushaira Mosharraf		TIME VISIT/ INSPECTION COMPLETED:	04:10 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	On August 13, 2024, at 1:00pm, Licensing Program Analyst (LPA) Edward Kim conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA Kim met with Applicants Mushaira Mosharraf and Shaira Mosharraf, and toured the facility. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to CCL on December 29, 2023. The facility is to have a capacity of six (6), of which six (6) can be nonambulatory and of which one (1) may be bedridden. Applicant has requested a hospice waiver for six (6) residents. Facility phone number (714)723-6746. LPA Kim observed the following. Structure: The facility is a one story house with an attached 2 car garage with four (4) bedrooms (1 is for staff), 2 bathrooms, dining room, a kitchen, and a living room. There are 4 exits: one exit door in the kitchen, one in the living room, one in the front door, and one in bedroom #3 which is the bedridden room. Air/Heating: Central air/heating system installed with a central panel to control entire house located in the hallway. Resident Bedrooms: There are three (3) Resident Bedrooms. The bedrooms are spacious and will easily accommodate the residents' belongings. All resident rooms had the required furnishings. Bedrooms Staff: There is one bedroom designated as the staff bedroom Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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: AMARI HOUSE	FACILITY NUMBER: 306006480
	VISIT DATE: 08/13/2024

NARRATIVE

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Bathrooms:
All bathrooms have a working toilet, wash basin and shower. All bathrooms are clean.

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

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed and posted in the hallway. Menus posted and available on the rerigerator. 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. The emergency food, emergency water, and emergency supplies are stored in the garage.

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors/carbon monoxide detectors are hardwired and tested operational. There is a fire extinguishers mounted on the wall in the kitchen. The fire extinguisher is fully charged.

Appliances:
There is one five (5) gas burner stove which lights unassisted, oven, microwave oven, 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 in the pantry and all extra cleaning supplies are locked in the garage..

Water Temperature:
Hot water was measured in all bathrooms. Hot water measured between to 100.7 degrees Fahrenheit.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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: AMARI HOUSE	FACILITY NUMBER: 306006480
	VISIT DATE: 08/13/2024

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Medications, First-Aid Kit & Book:
The first aid kit and the first aid manual are stored in pantry in the kitchen. The first aid kit has all the required elements. Medications will be stored in the cabinet above the sharps, cleaning supplies, and first aid kit and first aid manual cabinet. The cabinets are kept locked.

Resident & Staff Files:
The Resident and Staff Records will be kept locked in filing cabinets located in the staff bedroom..

Reading Material, Games, Equipment & Materials:
Books and board games are stored in the living room. There is a large screen TV in the living room.

Fire clearance:
Fire Clearance approved by Anaheim Fire Department on January 30, 2024.

Component III:
Component three

During the pre-licensing inspection, LPA Kim observed the following items that must be corrected: 1) backyard needs to be clean by removing oranges on the ground, 2) left side gate door does not open/close as intended, 3) the brick pathway is not a stable walkway and could be a potential safety concern, 4) water temperature in resident bathroom did not measure between 105 degrees Fahrenheit and 120 degrees Fahrenheit. The water temperature measured at 100.7 degrees Fahrenheit, and 5) there is no tablet, computer, or laptop available for the residents to use for internet access.

The applicant plans on making the necessary corrections and contacting LPA Kim to schedule a follow up pre-licensing inspection.

Exit interview was conducted and a copy of this report was provided to applicants Mushaira Mosharraf and Shaira Mosharraf. LPA Edward Kim will submit a copy of the facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC809 (FAS) - (06/04)

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