<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006559
Report Date: 08/15/2024
Date Signed: 08/15/2024 03:47:36 PM

Document Has Been Signed on 08/15/2024 03:47 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:PROPER LIVING SENIOR CAREFACILITY NUMBER:
306006559
ADMINISTRATOR/
DIRECTOR:		SALAZAR, ANTHONYFACILITY TYPE:
740
ADDRESS:12892 ADAMS ST.TELEPHONE:
(714) 583-9477
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY: 6CENSUS: DATE:
08/15/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Anthony SalazarTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Licensee/ Administrator Anthony Salazar. Consultant John Atencio was present as well. An initial application to operate a Residential Care Facility for the Elderly was submitted to Community Care Licensing on 04/10/2024 for a capacity of five non-ambulatory and one bedridden resident. Upon entry, facility appears clean, safe and sanitary. Facility has all required postings at entrance. Administrator Anthony Salazar has an administrator certificate expiring on 01/10/2026.
LPA Lyman along with Licensee/ Administrator and Consultant toured the facility at 8:15 AM and observed the following:
Structure: Facility is a one story, 4 bedroom, 2 bathroom house with a tan exterior and attached garage. The outside exit gate is closed and unlocked. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: Rooms will be single and double occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Linens & Hygiene Supplies: Facility has ample bedding and towels in supply. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Emergency Phone Numbers and Exit Plan: Posted in the entrance of the facility. Food Service: Facility has 2 day perishables as well as 7 day non-perishables. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguisher is fully charged. Facility has a fire door to hallway with bedrooms. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: Facility has secured areas for toxins and sharps. Water Temperature: Tested and recorded between 116 and 116.9 degrees F. in facility bathrooms. Emergency Supplies: LPA observed ample emergency food and water as well as a posted emergency disaster plan.
CONTINUED ON LIC 9099C DATED 08/15/2024.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PROPER LIVING SENIOR CARE
FACILITY NUMBER: 306006559
VISIT DATE: 08/15/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Medications, First-Aid Kit & Book: First aid kit observed contained all required items including tweezers, scissors and thermometer. LPA observed a first aid manual. Medication is stored in a locked cabinet. Facility to use a medication administration record. Resident & Staff File: Records are to be stored in a secured file cabinet. Reading Material, Games, and Equipment: LPA observed a sample activity schedule with activities such as games and exercise. Backyard: LPA observed a clean backyard with ample shaded seating for residents. Fire Clearance: Approved for five non-ambulatory and one bedridden resident on 05/08/2024.


Component III conducted during the visit.

Facility is ready to be licensed.


Exit interview conducted and a copy of this report was left at the facility
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2