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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006589
Report Date: 11/20/2024
Date Signed: 11/20/2024 03:59:09 PM

Document Has Been Signed on 11/20/2024 03:59 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:DEDICATED GUEST HOMEFACILITY NUMBER:
306006589
ADMINISTRATOR/
DIRECTOR:		OLTEANU, CLAUDIAFACILITY TYPE:
740
ADDRESS:5152 CASA ORO DRTELEPHONE:
(949) 232-9619
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 6CENSUS: 0DATE:
11/20/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Claudia OlteanuTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On November 20, 2024, at 1:00pm, Licensing Program Analyst (LPA) Edward Kim conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA Kim met with Applicant Claudia Olteanu and toured the facility.

An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to CCL on June 7, 2024. The facility has a capacity of six (6) residents, of which one (1) is ambulatory, four (4) can be nonambulatory and one (1) may be bedridden. Facility phone number (714-646-9158). LPA Kim observed the following.

Structure:
The facility is a one-story house with an attached 2 car garage with five (5) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, an office, dining room, a kitchen, and a living room. There are four (4) exits: one exit door in the dining room, one in the main entrance, one in bedroom #4 which is the bedridden room, and one next to bedroom #5.

Air/Heating:
Central air/heating system installed with a central panel to control entire house located in the living room.

Resident Bedrooms:
There are five (5) Resident Bedrooms: Bedroom #1, Bedroom #2, Bedroom #3, Bedroom #4, and Bedroom #5. The bedrooms are spacious and will easily accommodate the residents' belongings. All resident rooms had the required furnishings.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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 3
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: DEDICATED GUEST HOME
FACILITY NUMBER: 306006589
VISIT DATE: 11/20/2024
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Staff Bedrooms:
There is one (1) Staff Bedroom.

Bathrooms:
All bathrooms have a working toilet, wash basin and shower. All bathrooms are clean. Shower mats were in all three bathrooms. Hot water was measured in all bathrooms. Hot water measured between 105.5 degrees Fahrenheit to 107.7 degrees Fahrenheit.

Linens & Hygiene Supplies:
Adequate supply of linen stored in hallway cabinets.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed and posted in the entrance hallway. Menus posted at the refrigerator.

Food Service:
There are no residents living in the facility currently. There is a 2-day perishable food. There is 7-day non-perishable food supply on hand. The emergency food and emergency supplies are stored in the garage. Emergency Water is stored in a closet between Resident Room #3 and Resident Room #4.

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors/carbon monoxide detectors are hardwired and tested operational. There are two (2) fire extinguishers. One is mounted on the wall in the kitchen, and one is mounted next the exit by the resident room 5. The fire extinguishers are fully charged and was serviced on November 11, 2024.

Outdoor/Yard:

There is an outdoor furniture with an umbrella to cover the table and chairs in the backyard. All outdoor gates are self-closing and self-latching.



Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: DEDICATED GUEST HOME
FACILITY NUMBER: 306006589
VISIT DATE: 11/20/2024
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Toxins:

All cleaning supplies and chemicals are kept in the garage and locked underneath the kitchen sink.


Medications, First-Aid Kit & Book:


The first aid kit and all medications are stored and locked in a cabinet in the hallway leading to resident room #5. The first aid kit has all the required elements.

Resident & Staff Files:
The Resident and Staff Records will be kept locked in a cabinet in the hallway leading to resident room #5.

Reading Material, Games, Equipment & Materials:
Board games are stored in the staff office. There is a large screen TV in the living room.

Appliances:
There is one five (5) gas burner stove which lights unassisted, oven, microwave oven, a refrigerator in the kitchen, a refrigerator in the garage, dishwasher, washer, and dryer. All appliances are clean and operational.

Fire clearance:
Fire Clearance approved by Orange County Fire Authority on July 3, 2024.

Component III:
Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities.

The pre-licensing visit and Component III Orientation are now complete. It appears this facility meets the requirements for licensure. LPA Kim will forward this report to the Centralized Applications Bureau for review. The license will be granted upon completion of a final review and approval from the Centralized Applications Bureau.

Exit interview was conducted and a copy of this report was left with Applicant Claudia Olteanu.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC809 (FAS) - (06/04)
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