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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300607404
Report Date: 10/24/2022
Date Signed: 10/24/2022 11:50:48 AM

Document Has Been Signed on 10/24/2022 11:50 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: 6DATE:
10/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Administrator, Vernell LaurenceTIME COMPLETED:
12:00 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.

LPA toured interior and exterior of facility. The home is a two story 6 bedroom (3 client rooms and 3 staff rooms) 3 bathroom home with living room, kitchen, office and garage. Facility currently has 6 clients. LPA observed three clients at time of visit. Clients were observed relaxing in room watching TV. LPA observed facility has Department postings such as Emergency Evacuation Plan and personal rights posted. LPA toured all clients rooms, all rooms had required furnishings such as bed, chair, night stand and dresser. Bedrooms where within regulations. All restrooms observed contained working wash basin, soap, toilet paper and towels. Proper hand washing signs were posted.

Facility has some PPE supplies but not 30 days worth. LPA discussed importance of having 30 day supply on hand at facility. Facility has 2 refrigerators, 3 freezers and pantry with ample food supply. LPA has observed 2 days perishable and 7 days non perishable food supply. LPA observed facility has emergency food and water supply. Facility has a secured location for Client medication and files. LPA observed 6 of 6 client files. Facility has 30 days supply of medications for clients. Clients emergency contact info and Physician's reports are current. Facility has 3 Fire Extinguishers mounted and fully charged. Facility has several designated visitation areas.

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: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2022
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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