306006549-11-15-2024-22-AS-JCHO-DB2NT7-20241115094415

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006549
Report Date: 11/15/2024
Date Signed: 11/15/2024 09:44:26 AM

Document Has Been Signed on 11/15/2024 09:44 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:	HAPPY FAMILY GUEST HOME		FACILITY NUMBER:	306006549
ADMINISTRATOR/ DIRECTOR:	VALENCIA, IDA MARIE		FACILITY TYPE:	740
ADDRESS:	12041 GILBERT ST		TELEPHONE:	(714) 496-8302
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY: 6		CENSUS: 4	DATE:	11/15/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	07:00 AM
MET WITH:	Victoria Valencia- Applicant/CEO Idamarie Valencia- Administrator		TIME VISIT/ INSPECTION COMPLETED:	10:05 PM

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Licensing Program Analysts (LPA) Jessica Cho and Eboni Bentley arrived announced for the purpose of conducting a Pre-Licensing visit for a Change of Ownership (CHOW). LPA conducted the visit with Applicant/Chief Executive Officer (CEO) Victoria Valencia and Administrator (Admin) Idamarie Valencia. The initial application to operate a Residential Care Facility for the Elderly (RCFE) was received by the Department of Social Services on April 17, 2024 for age range 60 and over. This facility is vendored by the Regional Center of Orange County (RCOC). This is a Level 4I home.

LPAs began the tour of the interior and exterior portion of the facility with Applicant and Administrator Valencia, and observed the following:

Structure:

The facility is a single story property in a residential neighborhood comprised of four resident bedrooms and three resident bathrooms. LPAs observed all common areas which includes the living room, dining area, kitchen, and an attached two car garage which doubles as a laundry room. The Additional Dwelling Unit (ADU) is occupied by Administrator Idamarie and is under a different address: 12043 Gilbert St. Garden Grove. The backyard has two exit gates with one gate being secured as approved per the fire clearance. The patio also has sufficient shaded seating area.

Telephone Number:
Facility land line number (714) 867-6123 was tested and remains available.

Signal System:
No signal system, however residents utilize bells to alert the staff.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

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: HAPPY FAMILY GUEST HOME	FACILITY NUMBER: 306006549
	VISIT DATE: 11/15/2024

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Bedrooms:
The resident bedrooms had all required components, are spacious, and easily accommodates the residents’ furnishings.

Bathrooms:
Bathrooms were clean and operational. Grab bars were secure and bath slip mats were in place.

Linens and Hygiene Supplies:
Clean linens and hygiene supplies were observed to be fully stocked.

Appliances:
Stove burners, microwaves, refrigerator, freezer, and washer/dryer were inspected and operating.

Resident and Staff Files:
Resident and staff records will be maintained on site.

Reading Material, Games, Equipment, & Materials:
The facility maintains reading material and games in the living room cabinet..

Emergency Phone Numbers/Exit Plan:
Posted in the entry way on the bulletin board.

Postings:
The See Something, Say Something (PUB475) and the Ombudsman Poster were posted in the entry way. The Rights of the Resident Councils, Resident's Rights, Theft & Loss Policy, and Activity Schedule, and a copy of the Admission Agreement were posted on the bulletin board in the entry way.

Food Service and Menu:
Supply of seven day non-perishable and two day perishables were observed. The sample menu was available for review. The emergency food/water supply was also available in the garage.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

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: HAPPY FAMILY GUEST HOME	FACILITY NUMBER: 306006549
	VISIT DATE: 11/15/2024

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Smoke and Carbon Monoxide Detectors:
The dual functioning smoke detectors/carbon monoxide alert systems and auditory devices were tested and found to be operational.

Fire Extinguishers:
Two fire extinguishers were mounted, fully charged, and serviced on June 3, 2024.

Fire Clearance:
Approved on June 6, 2024 for 1 ambulatory, 4 non-ambulatory, and 1 bedridden. Please note that non-ambulatory is permitted in bedrooms 2 & 3 of which bedroom 2 is permitted for bedridden resident only. Bedrooms 1& 4 are designated for ambulatory residents.

Toxins and Sharps:
Cleaning supplies, toxins, and sharps were observed to be secured and inaccessible.

Water Temperature:
The water temperature in the three resident bathrooms measured at 117.6, 112.2, and 113.1 degrees Fahrenheit.

Medications, First Aid Kit, & Manual:
The First Aid Kit was checked and found to be in order. The first aid manual was also available.

Component III:

Component III was waived because Applicant is operating other licensed facilities and has fulfilled this requirement.

The Pre-Licensing is now complete, and the facility is ready for licensure. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau.

An exit interview was conducted with Applicant/CEO Victoria Valencia and Administrator Idamarie Valencia, and a copy of this report was provided at the end of the visit.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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