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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006522
Report Date: 06/07/2024
Date Signed: 06/07/2024 11:04:20 AM

Document Has Been Signed on 06/07/2024 11:04 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:CARE JORDAN 2FACILITY NUMBER:
306006522
ADMINISTRATOR/
DIRECTOR:		LIMPIADO, GIDEONFACILITY TYPE:
740
ADDRESS:17111 SAGA DRIVETELEPHONE:
(949) 612-7927
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 6CENSUS: 0DATE:
06/07/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Gideon Limpiado-Applicant, Nestor Librada-House ManagerTIME VISIT/
INSPECTION COMPLETED:
11:18 AM
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA met with Applicant Gideon Limpiado and toured the facility.

An application for Change of Location (CHOL) to operate a Residential Care Facility for the Elderly (RCFE) was submitted to Community Care Licensing (CCL) on February 15, 2024. The facility is to have a capacity of six, of which five can be nonambulatory and one bedridden. Facility phone number 714-203-1342. LPA observed the following.

Structure:
The facility is a one-story house with four resident bedrooms, one staff bedroom, three full size bathrooms, a living room, a kitchen, a dining room, and an attached car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall by the dining room. There is one gate in the backyard, which both is self-closing and self-latching. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard.

Air/Heating:
Central air/heating system installed with a central panel to control entire house.

Resident Bedrooms:
There are four resident bedrooms. All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets.


CONTINUED ON LIC809-C...
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CARE JORDAN 2
FACILITY NUMBER: 306006522
VISIT DATE: 06/07/2024
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Bathrooms:
All bathrooms are clean and have working plumbing. Hot water measured between 107.8 and 110.1 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen for each resident was stored in a closet by the resident's bedrooms hallway.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Sample menu was available in the file.

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 is a fire extinguisher mounted on the wall by the laundry room and one by the dining room.

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

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored in a locked cabinet in the garage.

Water Temperature:
Hot water was measured in all bathrooms. Hot water measured between 107.8 and 110.1 degrees Fahrenheit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
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: CARE JORDAN 2
FACILITY NUMBER: 306006522
VISIT DATE: 06/07/2024
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Medications, First-Aid Kit & Book:
The first aid kit and the first aid manual are stored in the closet by the dining room. The first aid kit has all the required elements. Medications will be stored in a locked cabinet by the dining room.

Resident & Staff Files:
The Resident and Staff Records will be kept in a locked cabinet by the dining room.

Reading Material, Games, Equipment & Materials:
Arts and craft, board games, books and puzzles are stored in a central storage in the living room. There is one large screen television in the living room.

Fire clearance:
Fire Clearance approved by a fire inspector of Orange County Fire Authority on April 24, 2024. Special conditions noted, "As per approved plan."

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


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: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC809 (FAS) - (06/04)
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