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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006514
Report Date: 05/03/2024
Date Signed: 05/03/2024 11:08:41 AM

Document Has Been Signed on 05/03/2024 11:08 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:POLLY'S PLACEFACILITY NUMBER:
306006514
ADMINISTRATOR/
DIRECTOR:		INES N OTBOFACILITY TYPE:
740
ADDRESS:420 MONTESSORI AVETELEPHONE:
(925) 448-1262
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 0DATE:
05/03/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Ines OtboTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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Licensing Program Analysts (LPAs) Claudia Gutierrez, Faith La, and Rose Ruppert made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPAs met with designated Administrator (AD) Ines Otbo, Assistant Administrator Joanne Otbo, and Licensee Marjorie Otbo. An application to operate a Residential Care Facility for the elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden residents was received by CCL on February 9, 2024.

Structure:
The facility is a one-story house with six resident bedrooms, one staff bedroom, four bathrooms, a living room, a kitchen, a dining room, a staff area, and attached two car garage. LPAs 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 each side of the house. There is a shaded seating area and LPAs did not observe any obstacles or hazards in the backyard.

Resident Bedrooms
All resident bedrooms had the required furnishings. LPAs observed all beds had linens and blankets.

Signal system
There is no signal system.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked underneath the kitchen sink.

Medications, First-Aid Kit & Book:
Medication will be stored in a locked cabinet. First aid kit is stored with the medication. The first aid kit has all the required elements.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: POLLY'S PLACE
FACILITY NUMBER: 306006514
VISIT DATE: 05/03/2024
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Resident & Staff Files:
Records will be kept in a locked file cabinet.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
Fire extinguishers were observed to be fully charged.

Reading Material, Games, Equipment & Materials:
The facility has reading books, and other recreational materials for resident use stored in the living room.

Fire clearance:
Was approved by a fire inspector of Placentia Fire Department on March 12, 2024. No special conditions noted.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Staff Bedrooms:
There is one staff bedroom.

Bathrooms:
All bathrooms have working plumbing. Hot water measured between 112.4-118.2 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in a hallway closet.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available, means of exiting, and emergency phone numbers. Food menu is available and posted.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: POLLY'S PLACE
FACILITY NUMBER: 306006514
VISIT DATE: 05/03/2024
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Food Service:
A supply of 2-day perishable and 7-day of non-perishable food was observed and will be maintained on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas burner stove, dishwasher, refrigerator, microwave, washer, and dryer are operational.

Facility sketch labels the staff office area as second “kitchen” however, Licensee stated that the area will be used as a staff office and will update and resubmit facility sketch to reflect the area as a staff office space. The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted and a copy of this report was provided to Licensee.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
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)
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