300607356-6-20-2025-22-AS-FARS-DHU24Q-20250620170419

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300607356
Report Date: 06/20/2025
Date Signed: 06/20/2025 05:04:41 PM

Document Has Been Signed on 06/20/2025 05:04 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 ANA	STATE: CA	ZIP CODE:	92707
CAPACITY: 6		CENSUS: 4	DATE:	06/20/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Sid Calub		TIME VISIT/ INSPECTION COMPLETED:	05:18 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Fred Arias an unannounced visit to the facility today to conduct an Annual inspection. LPA was greeted and granted entry by staff Edgar Barrido. During today’s visit, LPA met with administrators Sid Calub and Myrna Calub. The facility is a single-story building with an approved fire clearance of six ambulatory clients. The facility currently has a census of four cliets in care. LPA toured the facility at 2:20 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, and water. 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 110.3 and 118.5 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 one client watching TV and another spending time outside. LPA observed medication storage to be secured right by the kitchen and reviewed the centrally stored medications. Continued on LIC809-C dated 6/20/2025

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Fred Arias
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

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: CMC GROUP OF CO. INC. DBA.	FACILITY NUMBER: 300607356
	VISIT DATE: 06/20/2025

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Per review completed medications appear to be given as prescribed. First aid kit had all the required elements including tweezers, thermometer, and scissors.

LPA reviewed one staff record and four client records. There were discrepancies noted in the review of staff file. P&I was reviewed.

Based on the observations made during today’s visit, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Fred Arias
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/20/2025 05:04 PM - It Cannot Be Edited

Created By: Fred Arias On 06/20/2025 at 04:44 PM

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: CMC GROUP OF CO. INC. DBA.	FACILITY NUMBER: 300607356
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85096(h)(1)

A minimum of thirty five (35) classroom hours, as defined in Section 85001(c)(3), with the following uniform Core of Knowledge curriculum: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, staff 1 (S1) has not completed required DSP training which poses a potential health and safety risk to persons in care.
	POC Due Date: 07/18/2025
	Plan of Correction
1 2 3 4	Staff to complete required DSP training by POC due date and submit proof to LPA.

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:

	Fred Arias
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

LIC809 (FAS) - (06/04)

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