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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006611
Report Date: 12/11/2024
Date Signed: 12/11/2024 10:50:03 AM

Document Has Been Signed on 12/11/2024 10:50 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:SIGNATURE RESIDENT CAREFACILITY NUMBER:
306006611
ADMINISTRATOR/
DIRECTOR:		FARIS, KOLALEHFACILITY TYPE:
740
ADDRESS:25002 SAUSILITO STTELEPHONE:
(949) 510-5968
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 6CENSUS: 0DATE:
12/11/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Kolaleh Faris, Leila ShakibaTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analysts (LPAs) Ruth Martinez and Nancy Guillen conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPAs met with Kolaleh Faris and Leila Shakiba, Administrators.

A change of ownership application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (6) capacity, (0) ambulatory, (3) non-ambulatory, and (3) bedridden residents was submitted to CCL on 08/08/2024.

Structure:
The facility is a one story house with an attached garage with 6 resident bedrooms, 3 full bathrooms, 1 office, a living room, a dining room, and a kitchen. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with an exit walkway on both sides of the house with covered seating for the residents. Air/Heating: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms will accommodate 6 residents with all bedrooms being private rooms. Bedroom 4, 5, and 6 are designated as bedridden bedrooms. Bedrooms Staff: No awake-staff. Bathrooms: All bathrooms have a working toilet, wash basin, walk in shower. Linens & Hygiene Supplies: Adequate supply of linen stored in each bedroom. Emergency Phone Numbers, Exit Plan & Menu: Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food serve for one week. Food Service: Adequate supply of 7-day non-perishable and 2-day perishables are stored in the kitchen. Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired, were tested and found operational. Appliances: Gas four-burner stove, single oven, 1 refrigerator, dish washer, microwave, washer, and dryer are clean and noted to be operational. Toxins: All
Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SIGNATURE RESIDENT CARE
FACILITY NUMBER: 306006611
VISIT DATE: 12/11/2024
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and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are stored and locked in garage and underneath kitchen sink. Water Temperature: Tested and recorded maintained at a comfortable temperature and the water temperature measures 111.7 Fahrenheit degrees in facility bathrooms. Medications, First-Aid Kit & Book: Medication and first aid kit/book are stored and locked in a storage closet located between dining room and living room. Resident & Staff Files: Records will be kept locked in a cabinet located in the garage. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the residents use, commensurate with the plan of operation. Fire clearance: Was approved on 9/17/24. Component III: Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities. Applicant was reminded that it is required to notify LPA, within 5 business days of admitting the first client. This notification may be done by phone, email, or fax.

The applicant has met all pre-licensing requirements. LPA will submit notification to CAB in Sacramento for final review prior to license being issued.

Exit interview was conducted and a copy of this report was left with the applicant.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
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