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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006618
Report Date: 11/26/2024
Date Signed: 11/26/2024 11:09:44 AM

Document Has Been Signed on 11/26/2024 11:09 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:SUMMIT VIEW ASSISTED LIVING LLCFACILITY NUMBER:
306006618
ADMINISTRATOR/
DIRECTOR:		TANASE, STEFANIAFACILITY TYPE:
740
ADDRESS:2902 E SHADY FOREST LNTELEPHONE:
(714) 803-5315
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY: 6CENSUS: 0DATE:
11/26/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:09 AM
MET WITH:Stefania TanaseTIME VISIT/
INSPECTION COMPLETED:
11:19 AM
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On 11/26/2024 at 8:00AM Licensing program analyst's (LPA's) William Vanegas and Rose Ruppert conducted an announced visit for the purposes of pre licensing. LPA's were greeted and granted access to the facility by administrator (AD) Stefania Tanase. LPA's explained the purpose of the visit and began the tour of the facility at 8:09AM and observed the following.

The facility is a one storied home with four resident bedrooms and three bathrooms one of which is a guest bathroom and an attached two car garage. LPA's observed all client beds had linens and blankets and they are of good quality meaning, no strains or rips. LPA's observed four out of four bedrooms with screened windows, and the required furnishings meaning, lamps, chest drawers, a chair for seating, and the required storage space for clothing and personal items. LPA's observed all rooms with exit routes have operational alarms.

LPA's observed the kitchen area, and noted the following. Facility has a microwave, dishwasher, and gas stove. All of which were tested to be operational. Refrigerator was observed to be at 40 Degrees F, and the freezer was observed to be at 0 Degrees F. Licensee had no knives on site at the time of the visit, however they stated they will get some and buy a magnet lock to keep them locked.

LPA's observed bathrooms to be free of mildew and debris, and were in clean and sanitary order. LPA's observed showers to have operational grab bars, slip-resistant mats, and shower chairs in each of the showers. Toilet was tested to be operational and water tested in between 117.1 and 117.6 Degrees F.

LPA's observed all required postings to be posted at the main entrance of the facility including, personal rights, personal rights of resident council, visiting hours, ombudsman, emergency disaster plan, and PUB475. However PUB475 was not the required size, and licensee ordered the correct size and showed LPA's proof of the purchase during today's visit.
CONTINUED ON LIC809C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SUMMIT VIEW ASSISTED LIVING LLC
FACILITY NUMBER: 306006618
VISIT DATE: 11/26/2024
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LPA's toured outside of the facility, and observed the following. There is a large body of water (pool) that is secured by a 5 ft fence. The fence is locked and made inaccessible to residents unless they are being supervised. LPA's observed an outdoor shaded seating area, and a large grilling section powered by a propane tank that is secure and inaccessible to residents. Exit routes are free of any obstructions, LPA's observed a small shed on the east side of the house that contains gardening supplies and tools. This shed is locked and made inaccessible to residents. All exit doors on the exterior of the property are unlocked and residents are able to exit in the case of an emergency.

LPA's observed facility to have a 7-day supply of nonperishable food, and a 2-day supply of perishable food, and emergency water sufficient for residents in care. LPA's observed the facility to have planned activities for clients such as golf in the front yard, music days, church services, and balloon toss activities. LPA's observed facility to have a working smart phone used as a home phone, and device for making face-time calls to family members and physicians.

LPA's conducted the component Three Orientation with AD. 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 to Licensee.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC809 (FAS) - (06/04)
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