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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006521
Report Date: 05/28/2024
Date Signed: 05/28/2024 09:42:18 AM

Document Has Been Signed on 05/28/2024 09:42 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:ALL HEARTS HOME CARE LLCFACILITY NUMBER:
306006521
ADMINISTRATOR/
DIRECTOR:		OLIVA, MARIZA M.FACILITY TYPE:
740
ADDRESS:25142 LAS BOLSASTELEPHONE:
(562) 619-8656
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 6CENSUS: 0DATE:
05/28/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Levita HoganTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at facility was greeted and granted entry. LPA met with Levita Hogan, applicant and explained the visit.

An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (6) capacity, (3) ambulatory, (2) non-ambulatory, and (1) bedridden resident was submitted to CCL on 02/05/24.

Structure:
The facility is a two story house with an attached garage with 3 resident bedrooms, 1 staff bedroom, 2 full bathrooms, a living rooms, a dining room/kitchen on the first floor. The second floor of the facility will be occupied by licensee with three bedroom and 1 full bathroom. Staircase has a locked gate for inaccessibility to resident, no resident will reside on the second floor. The resident’s bedrooms on the first floor are spacious and will easily accommodate the resident’s furnishings. There is a gated pool in the back yard, seating areas for resident and an exit walkway on each side of the house. There is resident shaded seating on the front yard of the facility that is enclosed with a gate. Air/Heating: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms will accommodate 6 residents with 3 shared room accommodating two residents. Bedroom 1 will accommodate 2 ambulatory residents, bedroom 3 will accommodate 2 non-ambulatory residents, and bedroom 4 will accommodate 1 bedridden and 1 non-ambulatory residents. Bedrooms Staff: Bedroom 2 is designated for live in caregiver. Bathrooms:
Facility has two full bathrooms on the first floor. All bathrooms have a working toilet, wash basin, walk in shower. Linens & Hygiene Supplies: Adequate supply of linen in storage.Emergency Phone Numbers, Exit Plan & Menu: Posted & readily available for review an emergency disaster plan with means of exiting

Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2024
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: ALL HEARTS HOME CARE LLC
FACILITY NUMBER: 306006521
VISIT DATE: 05/28/2024
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and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food serve for one week.Food Service: Adequate supply of 7-day non-perishable and 2-day perishables will be stored in the kitchen. Additional food storage in garage in spare refrigerator located in garage.Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired, were tested, and found operational. 1 fire extinguishers mounted in kitchen, charged, and dated September 01, 2023.Appliances: Electric four burner stove, single oven, two refrigerators (kitchen/garage), microwave, dishwasher, washer, and dryer are clean and noted to be operational. Toxins: All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are stored and locked in the garage cabinet. Water Temperature: Tested and recorded maintained at a comfortable temperature and the water temperature measures 105.9 Fahrenheit degrees in facility bathrooms. Medications, First-Aid Kit & Book:
Medication will be stored in a locked cabinet located in the kitchen. First Aid kit and book are stored in storage closet adjacent to kitchen and main entrance of facility. Resident & Staff Files: Records will be kept locked in storage closet located adjacent to kitchen and main facility entrance. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the resident's use, commensurate with the plan of operation. Pool/Jacuzzi & Pets: Facility has a swimming pool in the backyard with a fence around it. The pool gate has a 2 self-latching entry door which opens inward towards the pool. The fence has a key padlock at the 2 gate entry doors for inaccessibility. The pool gate measures 5.25ft from base of the floor to the top of the fence and it was observed to enclose the entire pool area. Fire clearance: Was approved on April 2, 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, within 5 business days of admitting the first client. 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.

Exit interview was conducted and a copy of this report was left with the applicant.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC809 (FAS) - (06/04)
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