306006531-5-8-2024-22-AS-JALE-D53P43-20240508105827

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006531
Report Date: 05/08/2024
Date Signed: 05/08/2024 10:58:45 AM

Document Has Been Signed on 05/08/2024 10:58 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:	CROWN VALLEY SENIOR HOME		FACILITY NUMBER:	306006531
ADMINISTRATOR/ DIRECTOR:	AVILA MARIA JASMIN		FACILITY TYPE:	740
ADDRESS:	30471 VIA ALCAZAR		TELEPHONE:	(714) 609-2303
CITY:	LAGUNA NIGUEL	STATE: CA	ZIP CODE:	92677
CAPACITY: 6		CENSUS: 0	DATE:	05/08/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:20 AM
MET WITH:	Maria Avila		TIME VISIT/ INSPECTION COMPLETED:	11:25 AM

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	Licensing Program Analyst (LPA) Joseph Alejandre made an announced visit to conduct the pre-licensing inspection. LPA met with applicant Maria Avila and toured the facility. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to CCL on March 8, 2024. The facility is to have a capacity of 6 nonambulatory of which one can be bedridden (in bedroom 5 only). Applicant has requested a hospice waiver for 6 residents. Facility phone number 949-503-1864. LPA observed the following. Structure: The facility is a one story house with an attached 2 car garage with 5 bedrooms, 2 bathrooms, dining room, kitchen and living room with a screened fireplace. There are 9 exits, a sliding glass door in each bedroom (5) and one in the kitchen (1) and living room (1). In addition an exit door is in the garage(1) and the front door (1). LPA observed the PUB 475 poster posted next to the front door. Air/Heating: Central air/heating system installed with a central panel to control entire house. Resident Bedrooms: There are 5 Resident Bedrooms. Bedroom number 2 is a shared room, the rest are private. Bedroom 5 is approved for 1 bedridden resident. The bedrooms are spacious and will easily accommodate the residents' belongings. All resident rooms had the required furnishings and linens. Medications, First-Aid Kit: The first aid kit is stored in a cabinet in the dining room. The first aid kit t has all the required elements. Medications will be stored in a cabinet in the kitchen. The cabinet is kept locked.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

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: CROWN VALLEY SENIOR HOME	FACILITY NUMBER: 306006531
	VISIT DATE: 05/08/2024

NARRATIVE

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Bathrooms:
Both bathrooms have a working toilet, wash basin and walk in shower, Both bathrooms are clean and operational. In bathroom two, located in bedroom two (the shared room) the ceiling vent fan is not operational. The window screen in bathroom two has a large hole in it.

Linens & Hygiene Supplies:
Adequate supply of linen stored in the hall closet.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. 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.

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors/carbon monoxide detectors tested operational. The fire extinguisher mounted by the front door is fully charged.

Appliances:
There is one 5 gas burner stove which lights unassisted, 1 oven, microwave oven, a refrigerator, dishwasher, washer, and dryer. All appliances are clean and operational.

Toxins:
All cleaning supplies and chemicals are kept are locked in the garage. Knives are kept locked in a kitchen cabinet.

Water Temperature:
Hot water was measured in both bathrooms. Hot water measured between 111.7 to 112.6 degrees Fahrenheit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

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: CROWN VALLEY SENIOR HOME	FACILITY NUMBER: 306006531
	VISIT DATE: 05/08/2024

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

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

Fire clearance:
Fire Clearance approved by Orange County Fire Authority Inspector Ryan Boselo on March 19, 2024.

Backyard: The backyard has a covered patio. Both exit gates are operational. There is no furniture in the backyard. The backyard is not appropriately equipped for outdoor use.

Component III:
Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities.

The following items must be corrected prior to licensing. The ceiling fan in bathroom two must be repaired. The window screen in bathroom two must be replaced. There must be a patio table and chairs for outdoor activities.

The facility is not ready to be licensed. Applicant was informed today that the final approval will be processed by CAB (Central Applications Bureau) in Sacramento. Applicant was informed to contact the LPA to schedule the next pre-licensing visit when items listed above have been corrected.

An exit interview was conducted and a copy of this report was left with the applicant.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

LIC809 (FAS) - (06/04)

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