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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300607257
Report Date: 12/09/2022
Date Signed: 12/09/2022 11:14:00 AM

Document Has Been Signed on 12/09/2022 11:14 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 & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:A.L. HOME CARE IIFACILITY NUMBER:
300607257
ADMINISTRATOR:AMANTE, LUZFACILITY TYPE:
735
ADDRESS:2322 W. CAMDEN PLACETELEPHONE:
(714) 432-1126
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY: 6CENSUS: 5DATE:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Pearly Tanla and Ann AmanteTIME COMPLETED:
11:20 AM
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Licensing Program Analysts (LPAs) Lydia Martinez and Alvaro Ramirez, Jr. conducted an unannounced visit for the purpose of conducting a required annual visit. LPAs were greeted and granted entry into facility by Caregiver Pearly Tanla. LPAs explained the reason for the visit. Administrator (AD) Ann Amante arrived shortly after.

At 10:24 a.m., LPAs and Caregiver Tanla conducted a tour of the inside of the facility, common areas, Client rooms, and kitchen. Staff working at facility was observed to be wearing a face mask during the visit. Four Clients were present during today’s visit. Facility is a 5-bedroom, 2-bathroom, single story home with an attached garage. LPAs observed a screening and sanitizing station at the entrance of the facility. Three Clients were observed resting in their respective rooms and one Client was coloring a book. All Client rooms had required elements, including bed, chair, nightstand, closet space, and ample lighting. Restrooms are stocked with soap and paper towels and have hand washing posting signs. Facility has required Department postings including Valid License, Complaint Poster (PUB 475), Emergency Disaster Plan, Infection Control Plan and Personal Rights. LPAs observed the facility to have approximately a two-day perishable and seven-day non-perishable supply of food for Five Clients in care.

LPAs observed facility has 72-Hour emergency food and water supply. Centrally stored medications are locked in a closet by the entrance hallway. LPAs toured the outside grounds and observed the shaded outside visitation area. Exit gate is unlocked and self-closing. Facility has a plan for Covid testing Clients and Staff as needed as well as a plan for isolation and quarantine. All Staff and all Clients are vaccinated for COVID-19. LPAs observed a four-week supply of PPE.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with AD Amante and a copy of this report was provided at time of exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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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