300613018-4-12-2023-22-AS-LMAZ-CQU6RH-20230412210220

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300613018
Report Date: 04/12/2023
Date Signed: 04/12/2023 09:04:13 PM

Document Has Been Signed on 04/12/2023 09:04 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	DISTOR'S RESIDENTIAL CARE II		FACILITY NUMBER:	300613018
ADMINISTRATOR:	LORI COOK		FACILITY TYPE:	735
ADDRESS:	23456 WHITE DOVE		TELEPHONE:	(949) 587-9380
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 6		CENSUS: 3	DATE:	04/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Maria "Lita" Manuel		TIME COMPLETED:	11:30 AM

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 Analysts (LPA) Lydia Martinez made an unannounced visit to conduct a Required – 1 Year inspection. Upon arrival LPA was greeted by facility Staff Maria "Lita" Manuel and was granted entry. LPA began inspection with introduction and visit purpose. There are currently 3 Clients residing at the facility. One client and one staff were present during today's visit. Per Staff Lita, two clients were away at Day Program. LPA spoke to Administrator Lori Cook via telephone and purpose of visit was explained. LPA Martinez, along with Staff Lita conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following: Facility is a single-story house with three client bedrooms, two bathroom, one staff bedroom, one guest bedroom and an attached 2 car garage that is used for storage. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. The back yard has a shaded sitting area. Client bedrooms were observed to be spacious and easily accommodate furnishings such as lamps, chair, dresser and a bed. Bathrooms were clean, faucets, showers and toilets were operational. Hot water temperature in client bathroom was within regulatory requirements. Linen and hygiene supplies were stocked in hallway closet. Emergency Phone Numbers and Exit Plan were reviewed. Food prep area is clean and organized. Food supply meets the requirement of one (1) week supply of non-perishable and two (2) day supply of perishables. Emergency food and water supply is available. Smoke detectors and carbon monoxide detectors were found to be operational. Fire Extinguishers were charged and mounted and were last serviced on 03/08/2023. LPA reviewed facility's Emergency Disaster/Fire drill log that shows last fire drill was on 04/04/2023. Stove burners, microwave, washer, and dryer are operational. Chemicals and sharps are made inaccessible to the clients. Laundry is done in the garage. Medications are centrally stored in a locked medication cart. Medications reviewed appear to have been dispensed accurately. (see LIC809C)

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: DISTOR'S RESIDENTIAL CARE II	FACILITY NUMBER: 300613018
	VISIT DATE: 04/12/2023

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First-Aid Kit had all the required elements. There is no land line in the facility, but has a cell phone (714) 587-9380 that is used and is kept in the facility at all times.

LPA reviewed three client files and one staff files. LPA interviewed 1 of 3 clients and 1 staff. The clients P&I records were reviewed, LPA observed that an individual log is maintained for each client. All monies are accounted for and logs were kept to date.

Indoor and outside passageways are free of obstruction.

In order to update CCL file, please provide the following updated documents to CCL by 04/25/2023: 1.) Designation of Administrative Responsibility (LIC308) 2.) Personnel Report (LIC500); 3.) Emergency Disaster Plan (LIC610D); 4.) Surety Bond; and 5.) Administrator certificate.

Based on observations made during today's visit in the areas reviewed, there are no deficiencies being cited per Title 22, Division 6 of The California Code of Regulations. Copy of this report and LIC9102 Advisory Notes will be sent to email on file.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC809 (FAS) - (06/04)

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