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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530074
Report Date: 12/27/2022
Date Signed: 12/27/2022 12:16:53 PM

Document Has Been Signed on 12/27/2022 12:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ALOHA SENIOR LIVING LLCFACILITY NUMBER:
365530074
ADMINISTRATOR:HAMILTON, CAROL KANANIFACILITY TYPE:
740
ADDRESS:8880 TANGERINE AVENUETELEPHONE:
(714) 323-8445
CITY:HEPERIASTATE: CAZIP CODE:
92345
CAPACITY: 4CENSUS: DATE:
12/27/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Carol K. Hamilton, AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Amber Coleman conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. The initial application to operate a Residential Care For the Elderly facility (RCFE) was submitted to the Central Applications Unit (CAU) on 10/21/2022 for a total capacity of four non-ambulatory residents. Fire Clearance was granted 11/10/2022. LPA Coleman observed the following:

Structure: Facility is one story. Three bedrooms. 2 Living Areas, Kitchen, Laundry and attached Garage.

Heating/Cooling System: Central heating and air conditioning system installed with a central panel
located in the hallway to control entire house.

Bedrooms: Each resident bedroom will accommodate any non-ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke and carbon monoxide alarm. Each closet contains a number of shelves for storage.

Bathrooms: 2 resient bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Hand rails were observed near toilets and in showers/tubs. A secure cabinet underneath sink was observed for the storage of chemicals and cleaning supplies. Attached to the bathroom, is the securable Laundry Room. Chemicals observed to be kept in a secure bottom cabinet. Water temperature measured by applicant and thermometer read by LPA at 106 F.

Kitchen: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked cabinet in the hallway near the kitchen. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals in the dining area adjacent to the kitchen.

Living/Family room: There were two separate living/family areas with safe and adequate seating and furnishings are in good repair. Also, housed in this area are the activities.

Linens and Hygiene Supplies: An adequate supply of linens were available in the rooms and Bathroom closet.

Yards/Outside: The back was completed was a patio with adequate covered area for providing shade. There were no obstructions. There is one body of water; in ground pol located in the backyard. The backyard included a spacious furnished with adequate seating. However, the gate used to secure the pool was observed to be made of a mesh material. The material was head up by in ground poles to keep material upright. Each space secured by a latch. LPA concerned that mesh material being collapsible will still allow access to the pool area. The material can be climbed over; especially concerning in residents who are deemed non-ambulatory by way of Dementia.

Garage: Administrator explained that this area will be Non-accessible to residents. Transportation vehicles, slot machines, television and seating area observed in garage, which will be kept secure with door.

Emergency Phone Numbers, and Exit Plan: Let-Us-No poster, signs for infection control, Ombudsman poster and rights to resident and family councils posters are missing. Personal rights were posted. Facility exit plan posted in hallway above desk.

General items: The facility has smoke alarms and two carbon monoxide detectors. These were tested and found operational. Nightlights observed plugged in along walls. Resident records storage space has been allocated to cabinets built into wall in hallway outside of resident rooms. LPA observed a facility phone and it was verified to be operational.

The following items need to be corrected before the facility can become licensed:
A discernible amount of food and emergency supplies made separate from main supply of food. Additionally, making the gate more secure or covering the pool to better deny access to the pool by potential residents.

Applicant will notify LPA of completion of the above items and a second visit will be scheduled.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2022
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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