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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300613256
Report Date: 03/01/2022
Date Signed: 03/01/2022 02:13:41 PM

Document Has Been Signed on 03/01/2022 02:13 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:LITTLE HARBOR BOARD & CAREFACILITY NUMBER:
300613256
ADMINISTRATOR:PARKER, STACEY SHAWNFACILITY TYPE:
735
ADDRESS:551 S. HARBOR BLVD.TELEPHONE:
(714) 999-9990
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 4CENSUS: 1DATE:
03/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator, Stacey ParkerTIME COMPLETED:
02:20 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 Stacey Parker. LPA's temperature was checked. LPA explained the reason for the visit.

During the visit LPA toured the facility with Administrator Stacey Parker. Facility is a 3 bedroom and 2 bathroom single story home. There is 1 Client 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, hand sanitizer, toilet paper and hand towels. Water Temperature was measured at 108.1 degrees Fahrenheit. Restrooms had proper hand washing signs posted. Client was observed relaxing in bedroom.

Facility has ample PPE supply. Facility has 1 refrigerators and pantry with ample food supply. LPA observed facility has emergency food and water supply. Facility has operating smoke detectors and carbon monoxide detector. Facility has 1 fire extinguisher which is fully charged. Facility has evacuation plan posted. Facility has a secured location for Client medication and files. Facility has 30 days supply of medications for clients. LPA reviewed Client files during visit. Clients emergency contact information and physicians reports are current. Facility has designated visitation area.

An exit interview was conducted with Administrator Stacey Parker and copy of report was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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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