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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006597
Report Date: 01/28/2025
Date Signed: 01/28/2025 03:32:58 PM

Document Has Been Signed on 01/28/2025 03:32 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:JUNIPER VILLAFACILITY NUMBER:
306006597
ADMINISTRATOR/
DIRECTOR:		YUNG M LEEFACILITY TYPE:
740
ADDRESS:618 JUNIPER AVENUETELEPHONE:
(818) 437-0477
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 6CENSUS: 0DATE:
01/28/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:06 PM
MET WITH:Yung Lee
Darlene Lindley		TIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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Licensing Program Analysts (LPAs) Claudia Gutierrez and Fred Arias made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPAs met with designated Administrator (AD) Yung Lee and Assistant Administrator Darlene Lindley. An application to operate a Residential Care Facility for the elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden residents was received by CCL on July 1, 2024.

Structure:
The facility is a one-story house with four resident bedrooms, one staff office, three bathrooms, a living room, a kitchen, a dining room, and attached two car garage. LPAs observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entranceway. There is a backyard with an exit gate on each side of the house. There is a shaded seating area, and LPAs did not observe any obstacles or hazards in the backyard.

Resident Bedrooms
All resident bedrooms had the required furnishings. LPAs observed all beds had linens and blankets.

Signal system
There is no signal system.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked underneath the kitchen sink.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: JUNIPER VILLA
FACILITY NUMBER: 306006597
VISIT DATE: 01/28/2025
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Resident & Staff Files:
Records will be kept locked in the staff office.

Medications, First-Aid Kit & Book:
Medication will be stored and locked in the staff office. First aid kit is stored with the medication and contains all the required elements.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
Fire extinguisher was observed to be fully charged with service tag dated December 19, 2024.

Reading Material, Games, Equipment & Materials:
The facility has magazines, board games and other recreational materials for resident use stored in the living room.

Fire clearance:
Was approved by a fire inspector of the Fullerton Fire Department on November 21, 2024. Special conditions noted, ”All rooms approved for non-ambulatory, no bedridden clients. No sprinklers required. No delayed egress or locked gates. Garage shall not be used for office, sleeping, or living unless approved by building official. Any alteration, addition, changes to structure or use, shall be approved by building official.”

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Bedrooms Staff:
There is one staff office.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: JUNIPER VILLA
FACILITY NUMBER: 306006597
VISIT DATE: 01/28/2025
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Bathrooms:
All bathrooms have working plumbing. Hot water measured between 111.2- and 119.8-degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available, means of exiting, and emergency phone numbers.

Food Service:
A supply of 2-day perishable and 7-day of non-perishable food will be maintained on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas burner stove, refrigerator, microwave, washer, and dryer are operational.

Licensee to address the following corrections:

New facility sketch to be submitted to Centralized Applications Bureau (CAB) identifying bedroom being used as a staff office.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC809 (FAS) - (06/04)
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