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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006682
Report Date: 03/19/2025
Date Signed: 03/19/2025 10:48:11 AM

Document Has Been Signed on 03/19/2025 10:48 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:RETREAT AT LAS PALMAS, THEFACILITY NUMBER:
306006682
ADMINISTRATOR/
DIRECTOR:		OTBO, MICHELLEFACILITY TYPE:
740
ADDRESS:807 E LAS PALMAS AVENUETELEPHONE:
(562) 842-7539
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY: 6CENSUS: 0DATE:
03/19/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Applicant- Michelle OtboTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On March 19, 2025, at 8:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA Kim met with Applicant Michelle Otbo and toured the facility.

An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to CCL on December 5, 2024. The facility is to have a capacity of six (6) nonambulatory. Applicant has requested a hospice waiver for six (6) residents. Facility phone number (657-248-7381). LPA Kim observed the following.
Structure:
The facility is a one-story house with an attached 2 car garage with five (5) resident bedrooms, one (1) caregiver bedroom but facility sketch shows it as a nook, three (3) bathrooms, family room, dining room, a kitchen, and a living room. There are eight (8) exits: one exit door in the family room, one in the main entrance, an exit next to the bathroom and laundry room, one in bedroom #1, one in bedroom #2, one in bedroom #3, one in bedroom #4, and one in bedroom #5.

Air/Heating:
Central air/heating system installed with a central panel to control entire house located in the hallway. The house temperature is at 72 degrees Fahrenheit.

Resident Bedrooms:
There are five (5) Resident Bedrooms: Bedroom #1, Bedroom #2, Bedroom #3, Bedroom #4, and Bedroom #5. The bedrooms are spacious and will easily accommodate the residents' belongings. All resident rooms had the required furnishings.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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 4
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: RETREAT AT LAS PALMAS, THE
FACILITY NUMBER: 306006682
VISIT DATE: 03/19/2025
NARRATIVE
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Staff Bedrooms:
There is one (1) Staff Bedroom, but the facility sketch has it listed as a nook.

Bathrooms:
All bathrooms have a working toilet, wash basin and shower. All bathrooms are clean. Shower mats were in all three bathrooms. Hot water was measured in all bathrooms. Hot water measured between 116.9 degrees Fahrenheit to 118.7 degrees Fahrenheit.

Linens & Hygiene Supplies:
Adequate supply of linen stored in bathroom 2.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed and posted in the entrance hallway. Menus posted and available in the kitchen refrigerator.

Food Service:
There are no residents living in the facility currently. The emergency food, emergency water, and emergency supplies are stored in the garage.

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors/carbon monoxide detectors are hardwired and tested operational. There are four (4) fire extinguishers, which are mounted on the wall in the kitchen, family room, in the hallway next to the bathroom 1, and garage. The fire extinguisher is fully charged. All four fire extinguishers are missing the monthly inspection tag and were purchased on October 23, 2024, with a receipt attached on each fire extinguisher.

Toxins:
All cleaning supplies and chemicals are kept in the garage and locked underneath the kitchen sink.


Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: RETREAT AT LAS PALMAS, THE
FACILITY NUMBER: 306006682
VISIT DATE: 03/19/2025
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Outdoor/Yard:
There is an outdoor covered patio area in the backyard with enough tables and chair for the residents. There is a table and two chairs in the front in a shaded area. Outdoor gate is self-closing and self-latching. There is a fountain in the backyard without standing water. There is no intention to have water in the fountain and will be used as backyard décor.

Medications, First-Aid Kit & Book:
The first aid kit and all medications are stored in medical cabinet, which is in the dining room. The first aid kit has all the required elements.

Resident & Staff Files:
The Resident and Staff Records will be kept locked in filing cabinet in the Livingroom.

Reading Material, Games, Equipment & Materials:
There is a large screen TV in the living room.

Appliances:
There is an electric stove with four burners which lights unassisted, double oven, blender, microwave oven, a refrigerator in the kitchen, dishwasher, washer, and dryer. All appliances are clean and operational.

Fire clearance:
Fire Clearance approved by Fullerton Fire Department on January 27, 2025.

Component III:
Component three will be discussed on the next visit.

During the pre-licensing inspection, LPA Kim observed the following items that must be corrected:1) A video conference internet device such as a tablet, laptop, or smart phone dedicated to the residents, 2) Fire Extinguishers bought in October 23, 2024, need monthly inspection tags, and 3) A submission to CAB Pre-Licensing for the facility sketch to update the nook as a Staff Bedroom with a LIC200, old facility sketch, new facility sketch, and in writing the reason for updating the sketch.
Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
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: RETREAT AT LAS PALMAS, THE
FACILITY NUMBER: 306006682
VISIT DATE: 03/19/2025
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The applicant plans on making the necessary corrections and contacting LPA Kim to schedule a follow up pre-licensing inspection.

An exit interview was conducted, and a copy of this report has been provided to Applicant Michelle Otbo. LPA Edward Kim will submit a copy of the facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

Exit interview was conducted and a copy of this report was left with Applicant Michelle Otbo
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC809 (FAS) - (06/04)
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