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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006602
Report Date: 11/08/2024
Date Signed: 11/08/2024 06:44:16 PM

Document Has Been Signed on 11/08/2024 06:44 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:HUMBLE HEART HOMEFACILITY NUMBER:
306006602
ADMINISTRATOR/
DIRECTOR:		LEE,LADY YVETTEFACILITY TYPE:
740
ADDRESS:811 N PAULINE STREETTELEPHONE:
(626) 715-4853
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 6CENSUS: 0DATE:
11/08/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Lady LeeTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with designated Administrator (AD) Lady Lee. An application to operate an Residential Care Facility for the elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden residents was received by CCL on July 12, 2024.

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

Resident Bedrooms
All resident bedrooms had the required furnishings. LPA 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 in the laundry area.

Resident & Staff Files:
Records will be kept in a locked file cabinet.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HUMBLE HEART HOME
FACILITY NUMBER: 306006602
VISIT DATE: 11/08/2024
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Medications, First-Aid Kit & Book:
Medication will be in a locked cabinet. First aid kit is stored with the medication and has all the required elements.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
Fire extinguisher is fully charged.

Reading Material, Games, Equipment & Materials:
The facility has reading books, activity books, arts and crafts supplies, board games, puzzles, and other recreational materials for resident use stored in the living room.

Fire clearance:
Was approved by a fire inspector of Anaheim Fire Department on September 26, 2024. Special conditions noted, “Bedridden in ‘back’ bedroom.”

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 no staff bedroom.

Bathrooms:
Bathroom has working plumbing. Hot water measured at 113.5 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HUMBLE HEART HOME
FACILITY NUMBER: 306006602
VISIT DATE: 11/08/2024
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Emergency Phone Numbers, Exit Plan & Menu:
Posted and available, means of exiting, and emergency phone numbers. Food menu was posted and available.

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, dishwasher, refrigerator, microwave, washer, and dryer are operational.

Licensee to address the following corrections by November 22, 2024:

· New facility sketch consistent with floor plan to be submitted to Centralized Applications Bureau (CAB). Updated facility sketch must identify staff office and bathroom located in the garage.

LPA will make an additional announced visit to follow-up on corrections listed above. An exit interview was conducted, and a copy of this report was provided to designated AD.

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

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC809 (FAS) - (06/04)
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