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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006556
Report Date: 12/03/2024
Date Signed: 12/03/2024 11:39:04 AM

Document Has Been Signed on 12/03/2024 11:39 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:SWEETWATER SENIOR CARE IIFACILITY NUMBER:
306006556
ADMINISTRATOR/
DIRECTOR:
MOOSANI, HASHIMFACILITY TYPE:
740
ADDRESS:4531 RANCHGROVE DR.TELEPHONE:
(949) 387-1422
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY: 6CENSUS: 2DATE:
12/03/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Hashim Moosani
Saleem Moosani
TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analysts (LPA) Jerome Haley made an announced visit for the purpose of conducting a pre-licensing evaluation. LPA Haley was greeted and granted entry by applicants Hashim Moosani and Saleem Moosani.

Structure:


The facility is a single level structure, with an attached garage. There’s a total of 4 bedrooms (3 resident and 1 staff), one living room space, one dining area, and two bathrooms. Bedrooms (Residents): All bedrooms have the required furnishings: bed, lamp, chair, and storage space. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. Grab bars are tightly secured. Hot water temperature measured at 119.6 degrees Fahrenheit in bathroom 1 and 117.8 degrees Fahrenheit in bathroom 2. Kitchen: 4 of 4 burners were operational on the gas stove. Sharps are locked in a kitchen drawer near the stove. Hazardous chemicals are locked under the sink. Food Service: There’s a perishable food supply that meets regulation requirements. A nonperishable food supply was observed. Laundry: There's a laundry area in the garage with a washer and dryer. Toxins: All toxic chemicals and cleaning solutions are locked under the sink in the kitchen or in the garage and inaccessible to residents in care. Resident & Staff Files: Resident and staff files are stored in a locked cabinet above the locked medication cabinet in the kitchen. Medications/First-Aid Kit: Medications are store in the kitchen in a locked medication cabinet near the refrigerator. There’s a first aid kit equipped with all the necessary elements in the locked medication cabinet. Linens & Hygiene Supplies: An additional supply of linen is stored in the garage. Backyard/Exterior: There’s a large backyard with self-latching side exit gate. A shaded patio area with a table and reclining style chairs was observed. Additional chairs and tables were observed on the patio area. Bodies of Water: No bodies of water observed. Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational.

Continued on LIC809C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SWEETWATER SENIOR CARE II
FACILITY NUMBER: 306006556
VISIT DATE: 12/03/2024
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Fire Extinguisher: Observed full charged mounted on the wall in the kitchen near the dining room. Emergency Phone Numbers, House Rules, Exit Plan & Menu: Are posted on the wall near the entrance. Readily available for review is an emergency disaster plan, a list of emergency phone numbers, and personal rights. A sample menu is posted in the kitchen on the refrigerator.

Component III: Is not ready to be presented at this time. Component III will be presented after corrections are made and the follow up visit is completed.

Corrections: The applicant has corrections to make before the facility is ready to be licensed.
1) Repair or replace the fan/light on the stove/oven. Fan/light is not operating.
2) Remove/cover exposed wires in the living room (ceiling) & bedrooms (ceilings)
3) Clean all ceiling fans
4) Replace missing blinds in the living room sliding glass door.
5) Additional non-perishable food items (can goods)
6) Non-skid matts for showers


A follow up visit will be scheduled one Applicants have completed the necessary corrections.
An exit interview was conducted, and a copy of this report was provided to applicant Saleem Moosani.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
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