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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006510
Report Date: 07/16/2024
Date Signed: 07/16/2024 04:14:39 PM

Document Has Been Signed on 07/16/2024 04:14 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:CLOSE2HOME, INC.FACILITY NUMBER:
306006510
ADMINISTRATOR/
DIRECTOR:
RODRIGUEZ, MAGDAFACILITY TYPE:
740
ADDRESS:9932 DEBIOIS AVETELEPHONE:
(714) 803-6287
CITY:FOUNTIAN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 5DATE:
07/16/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Magda Rodriguez, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPA met with Licensee (LE) Magda Rodriguez. An application to operate a Residential Care Facility for the Elderly (RCFE) was received by our agency on February 5, 2024 for a total capacity of six non-ambulatory residents. There are currently five residents residing in the facility, Los Tiempos Senior Living #2 RCFE #306006194, that is to be transferred to Close2Home, Inc.

The facility is a one story home with four client bedrooms, two bathrooms, a living room, a kitchen, a dining area, and an attached two car garage. All exiting doors had alarm notifications. There are two backyard exit gates on the sides of the house that are self-latching and unlocked. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard. LPA observed the See Something, Say Something poster (PUB 475), Personal Rights, Visiting Hours and Emergency Disaster Plan in the facility mounted on the wall in the dining area. Client bedrooms had the required furnishings. LPA observed all beds had linens and blankets. All toxic chemicals, cleaning solutions, and disinfectants are inaccessible to residents and will be stored and locked underneath the kitchen sink. Medications will be stored in a locked cabinet in the garage. The first aid kit is stored in the garage and has all the required elements. Reading materials and games were observed in the living room with a cellphone for resident use. A supply of seven days of non-perishable food was observed and will be maintained on hand and has two day perishables. Smoke detectors and carbon monoxide detectors tested operational. Gas burner stove, dishwasher, refrigerator, microwave, washer, and dryer are operational.

LPA conducted the Component Three Orientation with LE. LE 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 provided to Licensee.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2024
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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