300602741-7-1-2025-22-AS-SHAN-DJ6P3G-20250701105731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300602741
Report Date: 07/01/2025
Date Signed: 07/01/2025 11:05:00 AM

Document Has Been Signed on 07/01/2025 11:05 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:	MARTINEZ FAMILY HOME		FACILITY NUMBER:	300602741
ADMINISTRATOR/ DIRECTOR:	LISSETTE OLAMENDI		FACILITY TYPE:	735
ADDRESS:	1412 WEST CHEVY CHASE DRIVE		TELEPHONE:	(949) 683-0994
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY: 6		CENSUS: 3	DATE:	07/01/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:16 AM
MET WITH:	TOSCANO DAYSI		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced Required 1-Year Annual Visit using the CARE Inspection Tool on [insert date]. Upon arrival at the facility, LPA met with Direct Support Professional (DSP) Daysi Toscano and explained the purpose of the visit.

The facility is licensed to operate for six (6) ambulatory clients. It is a single-story residence located in a residential neighborhood. The layout includes three client bedrooms, one staff bedroom, one activity room, two bathrooms, two living areas, a dining area, a kitchen, a swimming pool, an attached garage, and a covered outdoor patio area.

At the time of the visit, there were three clients in placement, all of whom were attending their day program.

LPA conducted a tour of the indoor and outdoor areas of the facility with DSP Toscano. There were no obstructions on the premises. The swimming pool was properly secured and locked by two gate doors, each five feet in height, located at different entrances. Both gates opened away from the pool, in compliance with safety standards.

All beds and bedding supplies were in good condition. Adequate lighting was observed throughout the facility, and clients had appropriate storage for personal belongings. The facility was adequately stocked with bed linens, comforters, and bath towels. All client bedrooms and the staff bedroom were inspected.

Bathrooms were clean and operational; however, the hot water temperature was measured at 134.2°F, which exceeds the allowable range under Title 22 regulations, constituting a violation.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: MARTINEZ FAMILY HOME	FACILITY NUMBER: 300602741
	VISIT DATE: 07/01/2025

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The physical environment was clean, sanitary, and appropriately furnished. Personal hygiene items, cleaning supplies, toxins, and sharp objects were stored securely and were not accessible to clients. The kitchen was inspected and found to contain a two-day supply of perishable food and a seven-day supply of non-perishable food, all of which were stored appropriately. The First Aid Kit was observed to be fully stocked and contained all necessary components.

Based on today’s observations, deficiencies are being cited in accordance with Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted with the facility representative. A copy of this report and appeal rights was reviewed and provided.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/01/2025 11:05 AM - It Cannot Be Edited

Created By: Samer Haddadin On 07/01/2025 at 10:44 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MARTINEZ FAMILY HOME	FACILITY NUMBER: 300602741
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in haviing the hot water at 134.2 DF which poses an immediate health, safety risk to persons in care.
	POC Due Date: 07/02/2025
	Plan of Correction
1 2 3 4	Licensee will fix the hot water temperature to reflect Title 22 regulation.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:

	Samer Haddadin
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025

LIC809 (FAS) - (06/04)

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