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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300607404
Report Date: 10/06/2021
Date Signed: 10/06/2021 04:07:12 PM

Document Has Been Signed on 10/06/2021 04:07 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: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:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Administrator, Vernell LaurenceTIME COMPLETED:
04:20 PM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and was granted entry into the facility by Administrator Vernell Laurence. LPA Tirre met with Administrator and explained the reason for the visit.

During the visit LPA toured the facility with Administrator, Facility is a 6 bedroom (3 client rooms 2 staff rooms) and 3 bathroom two story home. There are 5 Clients in care. LPA observed facility has required Department postings. LPA toured all clients rooms, all rooms where within regulations. All restrooms observed contained working water basin, soap, toilet paper and paper towels. Clients were observed relaxing in bedrooms.

Facility has PPE supplies. Facility has 2 refrigerators, 2 freezers and pantry with ample food supply. LPA observed facility has emergency food and water supply. Facility has evacuation plan posted. Facility has a secured location for Client medication and files. Facility has 30 days supply of medications for clients. Facility has 3 Fire Extinguishers mounted and fully charged.

An exit interview was conducted with Administrator and copy of report was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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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