306006624-4-15-2025-22-AS-ARJR-DFRN7K-20250415101248

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006624
Report Date: 04/15/2025
Date Signed: 04/15/2025 10:13:09 AM

Document Has Been Signed on 04/15/2025 10:13 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:	PALMS BAY GUEST HOME		FACILITY NUMBER:	306006624
ADMINISTRATOR/ DIRECTOR:	MARICA, ABEL		FACILITY TYPE:	740
ADDRESS:	13032 LAIRD STREET		TELEPHONE:	(949) 232-9619
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92843
CAPACITY: 6		CENSUS: 0	DATE:	04/15/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	07:59 AM
MET WITH:	Abel Marica-Applicant		TIME VISIT/ INSPECTION COMPLETED:	10:25 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA met with Applicant Abel Marica and toured the facility. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to Community Care Licensing (CCL) on September 05, 2024. The facility is to have a capacity of six residents, (1) ambulatory, (4) non-ambulatory and (1) bedridden residents. Applicant requested a Hospice Waiver for (6). Facility phone number is 714-583-8555. LPA observed the following. Structure: The facility is a one-story house with four resident bedrooms, two full size bathrooms, a living room, a kitchen, a dining room, and a garage Accessory Dwelling Unit. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall by entryway. There is one gate by the front entrance. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard. Air/Heating: Central air/heating system installed with a central panel to control entire house. Resident Bedrooms: There are four resident bedrooms. All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets. CONTINUED ON LIC809-C...

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Alvaro Ramirez Jr.
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: PALMS BAY GUEST HOME	FACILITY NUMBER: 306006624
	VISIT DATE: 04/15/2025

NARRATIVE

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Bathrooms:
All bathrooms are clean and have working plumbing. Hot water measured between 111.2-113.1 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen for each resident was stored in the closet by the residents' bedroom hallway.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was posted and available. Menu available and posted on the board.

Food Service:
There are no residents living in the facility at this time. There is 7-day non-perishable food supply on hand.

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors/carbon monoxide detectors are hardwired and tested operational. Fire extinguishers were charged, mounted and one was located by the entryway and one by the residents' bedroom hallway.

Appliances:
There is one gas stove, one oven, microwave oven mounted above the stove, a refrigerator, dishwasher, washer, and dryer. All appliances are clean and operational.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored in locked cabinets under the kitchen and restroom sinks.

Water Temperature:
Hot water was measured in all bathrooms. Hot water measured between 111.2-113.1 degrees Fahrenheit.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Alvaro Ramirez Jr.
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PALMS BAY GUEST HOME	FACILITY NUMBER: 306006624
	VISIT DATE: 04/15/2025

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Medications, First-Aid Kit & Book:
The first aid kit and the first aid manual are stored in a cabinet next to the dining room. The first aid kit has all the required elements. Medications will be stored in locked cabinet next to dining room.

Resident & Staff Files:
The resident and staff records will be kept in a locked cabinet in the living room.

Reading Material, Games, Equipment & Materials:
The activities plan include playing card games, books, newspaper reading and outings.

Fire clearance:
Fire Clearance approved by a fire inspector of Orange County Fire Authority on November 20, 2024. Special conditions noted, "Garage ADU approved for staff only; no client use. All bedrooms approved for ambulatory clients. Bedroom 1: Non-ambulatory. Bedroom 2: Non-ambulatory or bedridden. Bedroom 3: Non-ambulatory."

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

LPA advised Applicant to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for inquiries and to submit incident reports.

The applicant has met all pre-licensing requirements. LPA will submit notification to CAB (Central Applications Bureau) in Sacramento for final review prior to license being issued. Applicant was informed today that the final approval will be processed by CAB in Sacramento.

Exit interview was conducted and a copy of this report was left with the applicant.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Alvaro Ramirez Jr.
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025

LIC809 (FAS) - (06/04)

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