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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000049
Report Date: 08/15/2024
Date Signed: 08/15/2024 12:40:40 PM

Document Has Been Signed on 08/15/2024 12:40 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HALL FAMILY HOMEFACILITY NUMBER:
306000049
ADMINISTRATOR/
DIRECTOR:		RON SALDAFACILITY TYPE:
735
ADDRESS:1922 WEST FLORA STREETTELEPHONE:
(714) 434-0100
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY: 6CENSUS: DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Diane Hall-AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:53 PM
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Administrator (AD) Diane Hall.

For today’s visit, LPA observed one staff member on duty.

LPA observed the Administrator's Certificate for facility AD Diane Hall which expires on 12/11/2024.

LPA Ramirez toured the interior and exterior portions of the facility with AD Hall. The facility is a single level structure and is licensed for 6 ambulatory clients. For this visit, there are zero clients in care. There are a total of four bedrooms, of which three are private client bedrooms, and one private bedroom for staff. LPA Ramirez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens and adequate storage space. Smoke and carbon monoxide detectors were tested and operational. There are a total of two restrooms. Restrooms were observed to be in good repair and faucets and toilets were operational. Water temperature tested between 115.6-117.3 degrees Fahrenheit. Fire extinguisher was charged, and located by the dining room.

During today's visit LPA observed the following LPA observed chipped paint in the kitchen area and the clients bathroom, LPA observed red discoloration and rust in the bathroom sink by the entryway, LPA observed brown and black discoloration in the kitchen cabinets and kitchen floor, LPA also observed that the stove had black and brown discoloration and burnt food crumbs.

For the exterior portion, LPA Ramirez observed a shaded patio area with furniture, and the grounds were free of any hazards. There is one exit gate in the backyard. No bodies of water were observed.

CONTINUED ON LIC809-C...

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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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Document Has Been Signed on 08/15/2024 12:40 PM - It Cannot Be Edited


Created By: Alvaro Ramirez Jr. On 08/15/2024 at 11:49 AM
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: HALL FAMILY HOME
FACILITY NUMBER: 306000049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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 evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA observed chipped paint in the kitchen area and the clients bathroom, LPA observed red discoloration and rust in the bathroom by the entryway, LPA observed brown and black discoloration in the kitchen cabinets and kitchen floor, LPA also observed that the stove had black and brown discoloration and burnt food crumbs.
POC Due Date: 09/05/2024
Plan of Correction
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Licensee to email LPA proof of POC by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sheila Santos
LICENSING EVALUATOR NAME:Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HALL FAMILY HOME
FACILITY NUMBER: 306000049
VISIT DATE: 08/15/2024
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Per AD the facility will not accept clients until the Licensee has submitted the Fiscal Audit requested by California Department of Developmental Services (CDDS). Per AD the Fiscal Audit paperwork has to be approved by CDDS prior to accepting a new client.

For today's visit one deficiency was issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with AD Hall.

A copy of this report was provided at the time of exit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
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