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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006532
Report Date: 09/10/2024
Date Signed: 09/10/2024 12:19:54 PM

Document Has Been Signed on 09/10/2024 12:19 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:JUST LIKE YOUR ARE HOME 2FACILITY NUMBER:
306006532
ADMINISTRATOR/
DIRECTOR:		REROMA STEVELYNFACILITY TYPE:
740
ADDRESS:10265 SHERWOOD CIRCLETELEPHONE:
(818) 633-0211
CITY:VILLA PARKSTATE: CAZIP CODE:
92861
CAPACITY: 6CENSUS: 6DATE:
09/10/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Stevelyn Reroma - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility and were greeted and granted entry by designated Administrator (AD) Stevelyn Reroma. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden clients was received by CCL on 3/6/2024.

Structure: The facility is a one-story home with five resident bedrooms, three resident bathrooms, living room, kitchen, sitting area, two caregiver rooms, staff bathroom, office, laundry room and an attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the living room area. There is a back yard with one exit gate on one side of the house. There is a seating area in the backyard. LPA did not observe any obstacles or hazards in the backyard.

All resident bedrooms had the required furnishings and ample lighting. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened.

Signal System: Facility has as console that can plug into any socket. The console has 6 buttons numbered 1 through 6. Each resident is assigned a number and has their own button they can press via remote. When a resident presses the button, a doorbell rings and their associated number lights up on the console so that staff can go and check on resident requesting assistance.

All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residnets and will be stored and locked in the chemical closet in the kitchen.

Medication, First Aid Kit and Manual are stored in a locked cabinet in the kitchen. The first aid kit has all the required elements.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: JUST LIKE YOUR ARE HOME 2
FACILITY NUMBER: 306006532
VISIT DATE: 09/10/2024
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Resident & Staff Files are kept locked in cabinet in the laundry area. LPA reviewed three out of six resident files and three staff files. Each contained the required elements.

Fire extinguishers are charged and last serviced on 4/25/2024 as indicated by their attached service tags.

Activity Materials: The facility has books, magazines, crossword puzzles, puzzles, coloring books, board games and televisions.

Fire clearance was approved by a fire inspector of Orange County Fire Authority on 05/13/2024.

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

Staff Bedrooms: Two bedrooms will be occupied by staff. There is only one overnight staff currently.

All bathrooms have working plumbing and designated hand washing posters. Hot water measured between 105-120 degrees Fahrenheit in the three resident bathrooms. Resident bathrooms also have shower mats in all showers.

A supply of extra linen and hygiene supplies are stored in the hallway closets/cabinets.

Emergency Phone Numbers, Exit Plan & Menu are posted and available for review

Food Service: There is a 2-day supply of perishables and 7-day of non-perishable food on hand.

Smoke detectors and carbon monoxide detectors tested operational.

Appliances: Stove/oven, 3 refrigerators/freezers, dishwasher, microwave, washer/dryer are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report and the Component III presentation were provided to designated AD.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC809 (FAS) - (06/04)
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