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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300607356
Report Date: 06/22/2022
Date Signed: 06/22/2022 04:17:08 PM

Document Has Been Signed on 06/22/2022 04:17 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:CMC GROUP OF CO. INC. DBA.FACILITY NUMBER:
300607356
ADMINISTRATOR:CALUB, MYRNA V.FACILITY TYPE:
735
ADDRESS:2414 SOUTH PARK DR.TELEPHONE:
(714) 435-0876
CITY:SANTA ANASTATE: CAZIP CODE:
92707
CAPACITY: 6CENSUS: 2DATE:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Emma Frenandez, Isidro CalubTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with staff Emma Fernandez and stated the purpose of this visit. Administrator Isidro Calub arrived during the inspection and provided assistance.

The facility is a single level structure and licensed for four ambulatory. This facility offers Adult Residential Care for level two.

At about 2:25 pm, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed two clients in care and one staff member on duty. LPA Tapia reviewed Facility Personnel Report and noticed that staff Emma Fernandez was not associated with the facility. LPA Tapia informed Administrator that all staff need to be associated to the facility. Administrator showed proof that documents were sent for association. LPA toured the interior and exterior portions of the facility. There were four client rooms and one room for caregiver only. Client rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide, and auditory exit alarms were tested to be operational. LPA Tapia noticed in bedroom 4 the fan lights were not working. Administrator was notified. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 106.8 degrees Fahrenheit. Bathroom (2) was observed to be in good repair and provided with grab bars and hot water was measured at 103.8 degrees Fahrenheit. Administrator was made aware of the water temperature. Facility met the minimum two-day supply of perishable and seven day supply of non-perishable food stock requirements. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed to be charged and operational. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. LPA Tapia noticed tools left out in the open and had staff remove them immediately.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
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)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CMC GROUP OF CO. INC. DBA.
FACILITY NUMBER: 300607356
VISIT DATE: 06/22/2022
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Facility also had a two-car garage which is used for storage, emergency supplies and food storage. Kitchen was in good repair but knifes and cleaning supplies were not locked. LPA reminded Administrator that all knifes, and cleaning supplies need to be locked. On the side of the kitchen there was an operational washer and dryer. LPA Tapia reviewed the COVID 19 mitigation plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. No citation was issued. Three advisories were issued today.

LPA Tapia conducted an exit interview with Administrator Isidro Calub and copy of this report was explained and left at the facility.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
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
LIC809 (FAS) - (06/04)
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