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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006538
Report Date: 08/30/2024
Date Signed: 08/30/2024 03:32:23 PM

Document Has Been Signed on 08/30/2024 03:32 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ACE HOMEFACILITY NUMBER:
306006538
ADMINISTRATOR/
DIRECTOR:		AHMED, ASISFACILITY TYPE:
740
ADDRESS:2230 E JACARANDA AVETELEPHONE:
(949) 491-4847
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY: 6CENSUS: 0DATE:
08/30/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:23 PM
MET WITH:Asis Ahmed-ApplicantTIME VISIT/
INSPECTION COMPLETED:
03:47 PM
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Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Samer Haddadin conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA met with Applicant Asis Ahmed and toured the facility.

An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to Community Care Licensing (CCL) on February 29, 2024. The facility is to have a capacity of 6 residents, (0) ambulatory, (5) non-ambulatory and (1) bedridden residents. Waiver granted for Hospice Care for (6). Facility phone number is 714-202-3599 LPA observed the following.

Structure:
The facility is a one-story house with three resident bedrooms, one office/breakroom, 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 entryway. There are two gates in the backyard, which both are 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 three 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: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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: ACE HOME
FACILITY NUMBER: 306006538
VISIT DATE: 08/30/2024
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Bathrooms:
All bathrooms are clean and have working plumbing. Hot water measured between 116.2-117.6 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen for each resident was stored in the closet by the resident's bedroom 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. Menus posted and available. Monthly menu available and posted in the refrigerator.

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. Fire extinguishers were charged, mounted and one was located by the kitchen and one by the resident's bedroom hallway.

Appliances:
There is one electric burner stove which lights unassisted, one oven, microwave oven mounted above the stove, 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 the garage.

Water Temperature:
Hot water was measured in all bathrooms. Hot water measured between 116.2-117.6 degrees Fahrenheit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ACE HOME
FACILITY NUMBER: 306006538
VISIT DATE: 08/30/2024
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Medications, First-Aid Kit & Book:
The first aid kit and the first aid manual are stored in a cabinet next to the dining room. The first aid kit has all the required elements. Medications will be stored in locked cabinet next to dining room.

Resident & Staff Files:
The Resident and Staff Records will be kept in the staff's office.

Reading Material, Games, Equipment & Materials:
The activities plan include playing card games, gardening, newspaper reading and going on walks.

Fire clearance:
Fire Clearance approved by a fire inspector of Orange City Fire Department on April 24, 2024. Special conditions noted, "Fire clearance approved under the above noted conditions. Approved for 1 bedridden client in room #3 and 5 non-ambulatory with 2 non-ambulatory clients in room #1 and 2 non-ambulatory clients in room #2 and 1 non-ambulatory client in room #3 (shared with bedridden client."

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

LPA advised Applicant to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for inquiries and to submit incident reports.

The applicant has met all pre-licensing requirements. LPA will submit notification to CAB (Central Applications Bureau) in Sacramento for final review prior to license being issued. Applicant was informed today that the final approval will be processed by CAB 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: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC809 (FAS) - (06/04)
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