<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300607404
Report Date: 05/22/2023
Date Signed: 05/25/2023 08:46:05 AM

Document Has Been Signed on 05/25/2023 08:46 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LAURENCE RESIDENTIAL CAREFACILITY NUMBER:
300607404
ADMINISTRATOR:LAURENCE, VERNELLFACILITY TYPE:
735
ADDRESS:3722 S. ROSS ST.TELEPHONE:
(714) 662-7771
CITY:SANTA ANASTATE: CAZIP CODE:
92707
CAPACITY: 6CENSUS: 5DATE:
05/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Facility Administrator- Vernell LaurenceTIME COMPLETED:
01:40 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) Celine De Perio conducted a case management visit in conjunction to the complaint control number: 22-AS-20230307163014.

LPA De Perio explained reason for visit, and met with facility administrator (AD) Vernell Laurence and staff (S1) Patricia Ingram.

In addition, Regional Center Service Coordinator Maria Penaloza was present.

During today's visit, the following deficiencies were observed:

General Licensing Requirements:
80075 - Health Related Services
80087 - Buildings and Grounds

An exit interview was conducted with AD and S1. A copy of this report and Appeal Rights were explained and provided to AD and S1.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2023
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 2
Document Has Been Signed on 05/22/2023 01:26 PM - It Cannot Be Edited


Created By: Celine DePerio On 05/22/2023 at 12:37 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: LAURENCE RESIDENTIAL CARE
FACILITY NUMBER: 300607404

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2023
Section Cited
CCR
80075(k)(1)

1
2
3
4
5
6
7
80075 Health Related Services
(k) The following requirements shall apply to medications...
(1) Medication shall be kept in a safe and locked place...
This requirement is not met as evidence by:
1
2
3
4
5
6
7
As plan of correction (POC), facility will ensure that all medications/vitamins are locked and inaccessible to clients in care, and will provide proof of understanding to the assigned LPA on or by 5/23/23.
8
9
10
11
12
13
14
Based on LPAs observations, interviews and record review, facility failed to essure that medications were locked. LPA observed a pill box of medications and vitamins in an unlocked drawer located in the kitchen. This poses an immediate health and safety risk to clients in care.
8
9
10
11
12
13
14
Type B
05/29/2023
Section Cited
CCR80087(a)

1
2
3
4
5
6
7
80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is not met as evidence by:
1
2
3
4
5
6
7
As plan of correction (POC), facility will clean the client bathrooms and will provide proof of understanding to the assigned LPA on or by 5/29/23.
8
9
10
11
12
13
14
Based on LPAs observations, interviews and record review, facility failed to ensure that the facility was kept clean, safe and sanitary.
LPA observed that there was fecal debris on the outside of the toliet located in the upstairs bathroom.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Luz Adams
LICENSING EVALUATOR NAME:Celine DePerio
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2