Pre-licensing visit·February 5, 2025

Licensing Program Analyst (LPA) Claudia Gutierrez and Hanna Gough made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPA met with designated Administrator (AD) Shirley Hills. An application to operate a Residential Care Facility for the elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden residents was received by CCL on August 21, 2024. Structure: The facility is a two-story house with four bedrooms downstairs and 2 bedrooms upstairs, two bathrooms downstairs and one bathroom upstairs, one living room, one kitchen, one dining room, and attached two car garage. LPA observed a fire place in the living room that has a screen covering. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entranceway. There is a backyard with an exit gate on each side of the house with one as the emergency exit as designated on facility sketch. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard. Resident Bedrooms: All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets. Signal system: There is no signal system. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents. Medications, First-Aid Kit & Book: Medication will be stored in a locked cabinet. First aid kit is stored with the medication and has all the required elements. Resident & Staff Files : Records will be kept in a locked cabinet. Pool/Jacuzzi: There is an in-ground pool in the backyard enclosed by a bar fence five feet in height with a gate that opens away from the pool and is self-latching. Latch is located within 6 inches from the top of the gate. Fire Extinguisher: Fire extinguishers are fully charged with service tags dated December 10, 2024. Reading Material, Games, Equipment & Materials: The facility has board games, puzzles, and other recreational materials for resident use stored in the living room. Fire clearance: Was approved by a fire inspector of City of Placentia Fire Department on December 19, 2024. No special conditions noted. Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements. Bedrooms Staff: There are 2 staff bedrooms that are located on the second floor and inaccessible to residents. Bathrooms: All bathrooms have working plumbing. Hot water measured between 114.6- and 118.7- degrees Fahrenheit. Linens & Hygiene Supplies: A supply of extra linen was stored in a closet located next to one of the downstairs bathrooms. Emergency Phone Numbers, Exit Plan & Menu: Posted and available, means of exiting, and emergency phone numbers. Food menu was also posted and available. Food Service: A supply of 2-day perishable and 7-day of non-perishable food was observed and will be maintained on hand. Smoke Detectors: Smoke detectors and carbon monoxide detectors tested operational. Appliances: Gas burner stove, refrigerator, microwave, washer, and dryer are operational. The designated 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 at the end of the inspection.