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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300607356
Report Date: 06/18/2024
Date Signed: 06/18/2024 04:08:36 PM

Document Has Been Signed on 06/18/2024 04:08 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:CMC GROUP OF CO. INC. DBA.FACILITY NUMBER:
300607356
ADMINISTRATOR/
DIRECTOR:
CALUB, MYRNA V.FACILITY TYPE:
735
ADDRESS:2414 SOUTH PARK DR.TELEPHONE:
(714) 435-0876
CITY:SANTA ANASTATE: CAZIP CODE:
92707
CAPACITY: 6CENSUS: 4DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Myrna CalubTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to the facility today to conduct an Annual Random/Required Evaluation. At 1:30 PM LPA Tea was greeted and granted entry by Edgar Barrido, a direct service provider (DSP). During today’s visit, LPA met with administrator Myrna Calub and the assistant administrator, Isidro Calub of the facility.

The facility is a single-story building with an approved fire clearance of six ambulatory residents. The facility currently has a census of four residents in care.

LPA Tea with the direct service provider and assistant administrator toured the facility at 1:50 PM. The facility consists of: 4 private resident bedrooms, 2 bathrooms, staff room, living-room, kitchen with dining area, laundry and garage. LPA observed sharp objects locked and secured in a drawer in kitchen area and observed toxin substances to be locked and inaccessible to clients in care locked and secured in cabinets in the kitchen and underneath the kitchen sink. LPA toured the outside grounds, there is a front yard with ample shade and outdoor furniture. In the backyard there are sheds to store extra items for the facility. There are two self-latching gates on both sides of the house. The garage has additional food supplies, emergency food, water and supplies.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in the bathrooms, and testing auditory devices on all exits, The hot water temperature measured between 120 and 108 degrees F and all smoke detectors were operational. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed clients watching TV. LPA observed medication storage to be secured right by the kitchen and reviewed the centrally stored medications.

Continuation on LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CMC GROUP OF CO. INC. DBA.
FACILITY NUMBER: 300607356
VISIT DATE: 06/18/2024
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Per review completed medication appear to be given as prescribed. First aid kit had all the required elements including tweezers, thermometer, and scissors.

Around 2:03 PM LPAs reviewed three staff records, four client records. There were discrepancies noted in the review of client and staff files. Administrator certificate expired on June 17, 2023, however administrator has complied with all course work and is pending renewal at this time.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiency cited on this date.

An exit interview was conducted with administrator, Myrna Calub and a copy of the report was provided at the time of the visit

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC809 (FAS) - (06/04)
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