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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300602741
Report Date: 06/22/2022
Date Signed: 06/22/2022 03:34:16 PM

Document Has Been Signed on 06/22/2022 03:34 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MARTINEZ FAMILY HOMEFACILITY NUMBER:
300602741
ADMINISTRATOR:LISSETTE OLAINENDIFACILITY TYPE:
735
ADDRESS:1412 WEST CHEVY CHASE DRIVETELEPHONE:
(949) 683-0994
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 3DATE:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:49 PM
MET WITH:Sandra Hernan Dez-ToscaTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted and granted entry by staff. LPA explained the reason for the visit.
Facility is a single story house with an attached garage which is used for storage of food and supplies. Facility has 4 bedrooms, 2 bathrooms, kitchen, living room, family room and office. LPA observed residents in their rooms listening to music or watching TV. All residents rooms had the required elements and were clean and organized. Restrooms were clean and operational. Hot water measured 116.7 degrees Fahrenheit in both bathrooms. Facility smoke detectors and carbon monoxide detectors tested operational. Administrator has an administrator certificate expiring on 04/07/2023. LPA observed adequate emergency food and water as well as the first aid kit. LPA toured the outside grounds and observed a pool which is fenced and kept secured. Exit gates on each side of the house are both operational. There is a storage room in the backyard that is kept locked and used for storage. The storage room is inaccessible to clients. LPA did not observe any hazards or obstructions in the outside grounds. LPA observed the medication is kept locked in a kitchen cabinet. Facility has ample supply of PPE. Facility has an ample supply of cleaning products. No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022
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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