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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006643
Report Date: 02/19/2025
Date Signed: 02/19/2025 11:19:43 AM

Document Has Been Signed on 02/19/2025 11:19 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:LIFE CARE MANORFACILITY NUMBER:
306006643
ADMINISTRATOR/
DIRECTOR:		REROMA, STEVELYNFACILITY TYPE:
740
ADDRESS:22322 SAVONATELEPHONE:
(818) 633-0211
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 6CENSUS: 6DATE:
02/19/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Stevelyn ReromaTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at facility was greeted and granted entry. LPA met with Stevelyn Reroma, applicant and explained the visit.

An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden resident was submitted to CCL on 10/08/24.

Structure:
The facility is a two story house with an attached garage with 5 resident bedrooms, 1 full bathroom, 3 half restrooms, a living room, a dining room, kitchen on the first floor. The second floor of the facility will be occupied by live in staff with one bedroom and 1 full bathroom. Access to staircase is the door leading to the garage which can be locked for inaccessibility to resident, no resident will reside on the second floor. The resident’s bedrooms on the first floor are spacious and will easily accommodate the resident’s furnishings. The back yard has seating areas for resident and an exit walkway on each side of the house. Air/Heating:
Central air/heating system installed with a central panel to control entire house. Bedrooms Residents:
Bedrooms will accommodate 6 residents with 1 shared room accommodating two residents. Bedroom #1 approved for bedridden residents, Bedroom #2, 3, 4 approved for 1 non-ambulatory resident each. Bedroom #5 approved for 2 non-ambulatory residents. Bedrooms Staff: Second floor is designated for live in caregivers. Bathrooms: Facility has 1 full bathroom on the first floor and 3 half restrooms in bedroom #2, 3, & 5. All bathrooms have a working toilet, wash basin, walk in shower. Second floor has 2 full bathroom 1 bedroom, kitchen and a living room.

Continued LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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 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: LIFE CARE MANOR
FACILITY NUMBER: 306006643
VISIT DATE: 02/19/2025
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Linens & Hygiene Supplies: Adequate supply of linen in storage. 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 will be stored in the kitchen. Additional food storage in a freezer located in the garage. Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired, were tested, and found operational. 1 fire extinguishers mounted in kitchen, charged, and dated August 26, 2024. Appliances:
Electric four burner stove, single oven, refrigerators, freezer (garage), microwave, washer, and dryer are clean and noted to be operational. Toxins: All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are stored and locked underneath kitchen sink and in the storage closet located between dining room/living room. Water Temperature: Tested and recorded maintained at a comfortable temperature and the water temperature measures 116.2 Fahrenheit degrees in facility bathrooms. Medications, First-Aid Kit & Book: Medication will be stored in a locked cabinet located in the kitchen. First Aid kit and book are stored in storage cabinet adjacent medication cabinet. Resident & Staff Files:
Records will be kept locked in storage cabinet located in the kitchen. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the resident's use, commensurate with the plan of operation. Fire clearance: Was approved on November 12, 2024. Component III: Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities.

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: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC809 (FAS) - (06/04)
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