300607294-2-7-2025-22-AS-NGUN-DDP2FS-20250207162158

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300607294
Report Date: 02/06/2025
Date Signed: 02/07/2025 04:22:40 PM

Document Has Been Signed on 02/07/2025 04:22 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	C & A BOARD AND CARE		FACILITY NUMBER:	300607294
ADMINISTRATOR/ DIRECTOR:	PULIDO, CARMENZA		FACILITY TYPE:	740
ADDRESS:	25241 ERICSON WAY		TELEPHONE:	(949) 859-3162
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	02/06/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:22 PM
MET WITH:	Alfonso Pulido- Licensee, Claudia Pulido- Personnel		TIME VISIT/ INSPECTION COMPLETED:	04:50 PM

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Licensing Program Analyst (LPA) Nancy Guillen made an unannounced visit for the purpose of conducting a required annual Inspection. LPA was greeted and granted entry by Licensee Alphonso Pulido after explaining the purpose of the visit. This is a Residential Care Facility for the Elderly (RCFE) licensed to six non-ambulatory residents with a hospice waiver for one. The facility is a two-story home. The second floor of the facility is used for staff only; the first floor consists of two resident bedrooms, a staff bedroom, a half bath, and a shared bathroom, living room, dinning room, office, kitchen and attached garage.

During the inspection, LPA and Licensee conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, dining room, garage and observed the following:

LPA observed residents resting in their respective bedrooms. LPA observed two residents present at the facility and one resident was away at their day program. During todays visit there were two staff present. LPA observed the See Something Say Something Poster (PUB 475) mounted on the wall by the entry way. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets with additional linens stored in a garage closet. LPA observed bathrooms were clean and equipped with grab bars and non-skid floor mats. LPA observed all windows were appropriately screened. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 108.6 and 110.9 degrees Fahrenheit. LPA toured the outside of the facility and observed outdoor passageways were free of obstruction. LPA observed the backyard had a shaded sitting area with furniture for resident use. LPA observed a swimming pool with a fence around it. LPA observed the pool gate has a self-latching entry door. The fence has a key lock at the gate door for inaccessibility. LPA observed the facility had a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations.

Continued on LIC 809C

Armando J Lucero	TELEPHONE: (714) 703-2866
Nancy Guillen	TELEPHONE: (714) 724-3542
	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

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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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: C & A BOARD AND CARE	FACILITY NUMBER: 300607294
	VISIT DATE: 02/06/2025

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Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with a service date of May 14, 2024 and located by the kitchen. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. The garage is used for storage and is kept locked and inaccessible to residents. Toxic chemicals, cleaning solutions, and disinfectants were observed to be locked and inaccessible to residents in the garage and under the kitchen sink. Medication cabinet was observed to be locked and centrally stored the kitchen. LPA observed the First Aid Kit had all the required components. LPA observed the facility conducted their last emergency disaster drill on October 29, 2024 and is conducted every 3 months.

LPA began review of the records. LPA Guillen reviewed three resident records. All the required documentation were present and current in the residents’ files reviewed. LPA reviewed three employee records. All employee’s present have a criminal record clearance and were associated to the facility. LPA observed staff to have current First Aid certificates.

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. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2866
LICENSING EVALUATOR NAME: Nancy Guillen	TELEPHONE: (714) 724-3542
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

LIC809 (FAS) - (06/04)

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