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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006552
Report Date: 08/29/2024
Date Signed: 08/29/2024 01:05:31 PM

Document Has Been Signed on 08/29/2024 01:05 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:OAKWOOD MANORFACILITY NUMBER:
306006552
ADMINISTRATOR/
DIRECTOR:
TACSUAN III, DOMINADOR IFACILITY TYPE:
740
ADDRESS:12422 OAKWOOD STTELEPHONE:
(714) 276-4824
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 6CENSUS: 0DATE:
08/29/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Norajoy KinneyTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Applicant (AP) Norajoy Kinney, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on April 2, 2024. This is an initial application with no residents in care. During the inspection, LPA and AP observed the following: Structure: this is a one-story home. Facility is a 6-bedroom, 3-bathroom, 1 story house with one attached garage and one detached garage, both of which are used for storage. There is a back yard with a patio cover for the residents and a pool that is properly fenced. Facility telephone number is (657) 251-0539. Resident Bedrooms: the 4 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Lamps, chairs, linens, and storage for each resident bedroom inspected. Staff Bedrooms: LPA inspected the 2 staff bedrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 114 and 116 F degrees in the 3 bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan, and Menu: reviewed. Food Service: 7 days nonperishable and 2 days perishable food supply reviewed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: inspected. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen and garage. Medication cabinet is locked. First-Aid Kit and Activity Supplies: observed and available. Resident & Staff Files: this is an initial inspection and LPA observed storage space for resident and staff files. Fire clearance was approved by City of Garden Grove Fire Department on June 11, 2024 for 1 bedridden in bedroom #2 and 5 non-ambulatory. Backyard: backyard exit gate is operational and unlocked. Backyard has shaded area for outdoor activities and sufficient seating for residents. Component III was completed with AP during today’s inspection. AP will obtain liability insurance once the application is approved.
During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AP was informed today that the facility is ready for licensure and final approval will be processed by the CAB supervisor in Sacramento. An exit interview was conducted and a copy of this report was discussed with and provided to AP.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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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