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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006544
Report Date: 09/16/2024
Date Signed: 09/16/2024 10:13:54 AM

Document Has Been Signed on 09/16/2024 10:13 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ANDROMEDA ESCAPE INCFACILITY NUMBER:
306006544
ADMINISTRATOR/
DIRECTOR:		NAGHIBI, ALIFACILITY TYPE:
740
ADDRESS:17207 BUTTONWOOD STREETTELEPHONE:
(714) 322-1910
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 4DATE:
09/16/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Ali Naghibi - AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:29 AM
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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) Ali Naghibi. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden residents was received by CCL on 4/4/2024.

The facility is a one-story home with six resident bedrooms, three resident bathrooms, living room, kitchen, dining room, sitting area, caregiver room, office, laundry room, backyard 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 hallway. There is a back yard with two exit gates on one both sides of the house. There are two shaded seating areas 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.

Facility does not have a signal system. Instead, Residents have bells they can ring to request help. All resident are physically able to ring the bells.

All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked in the laundry room

Medication, First Aid Kit and Manual are stored in a locked cabinet in the laundry room. The first aid kit has all the required elements.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2024
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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ANDROMEDA ESCAPE INC
FACILITY NUMBER: 306006544
VISIT DATE: 09/16/2024
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Records are kept locked in cabinet in the laundry room. LPA reviewed three out of four resident files. Each contained the required elements.

All fire extinguishers are fully charged and were last serviced on 10/10/2023 as indicated by their attached service tags.

The facility has books, magazines, crossword puzzles, puzzles, coloring books and televisions.

Fire clearance was approved by a fire inspector of Fountain Valley Fire Department on 04/23/2024.

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

One bedroom will be occupied by staff. There is one overnight staff each night.

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 is stored in the hallway closets/cabinets.

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

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

Smoke detectors and carbon monoxide detectors tested operational.

Gas five burner stove with 1 oven, 3 refrigerators/freezers, dish washer, microwave, washer, and 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

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
LIC809 (FAS) - (06/04)
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