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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000341
Report Date: 03/29/2022
Date Signed: 03/29/2022 11:03:55 AM

Document Has Been Signed on 03/29/2022 11:03 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:W & E FAMILY HOMEFACILITY NUMBER:
306000341
ADMINISTRATOR:MARITES T. DE VERAFACILITY TYPE:
735
ADDRESS:25242 TURF AVENUETELEPHONE:
(949) 597-9166
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 3DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Wildy Tronco - Direct Support ProfessionalTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to W & E Family Home. The purpose of today's visit was to conduct a Required 1 Year inspection. LPA Velazquez was allowed entry into the facility and met with Direct Support Professional (DSP) Wildy Tronco. The facility is licensed for 6 ambulatory clients. There are currently 3 clients living in the facility. The last emergency disaster drill was conducted on January 18, 2022.


At 9:02 AM LPA Velazquez conducted a tour of the physical plant along with DSP Tronco. The 1 story home consists of 3 client bedrooms and 2 bathrooms. There is 1 staff bedroom. The facility also has a living room, dining area, and kitchen. The 3 clients were not at the facility at the time of the visit as they were attending their Day Programs. The client bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Client bath towels and personal hygiene supplies were adequately stocked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. LPA Velazquez tested the hot water temperature in the client bathrooms and the temperature measured at 106.8 degrees Fahrenheit in the first bathroom and at 109.5 degrees Fahrenheit in the second bathroom which DSP Tronco verified.

LPA Velazquez inspected the kitchen along with DSP Tronco. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. DSP Tronco could not provide copies of dated menus as served as requested by LPA Velazquez. The fire extinguisher was fully charged. The smoke and carbon monoxide detectors were tested and found to be operational. Medications, toxins and sharps were locked and inaccessible to clients.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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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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: W & E FAMILY HOME
FACILITY NUMBER: 306000341
VISIT DATE: 03/29/2022
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First Aid kit was checked and found to be in order. The facility did have a First Aid guide and LPA Velazquez advised DSP Tronco to obtain an updated First Aid manual.


LPA Velazquez along with DSP Tronco toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for clients. Walkways around the home were clear of hazards. There were no security bars or weapons on the premises.

No resident or staff files were reviewed at the time of this visit but LPA Velazquez provided DSP Tronco with consultation on providing emergency responders with pertinent client information in the event of a 911 call.



Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 1. An exit interview was conducted with Direct Support Professional Wildy Tronco and a copy of this report along with the appeal rights and LIC 9098 were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
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Document Has Been Signed on 03/29/2022 11:03 AM - It Cannot Be Edited


Created By: Patricia Velazquez On 03/29/2022 at 10:48 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: W & E FAMILY HOME
FACILITY NUMBER: 306000341

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(19)
80076(a)(19) Food Services. In facilities providing meals to clients, the following shall apply: (19) All equipment, fixed or mobile, dishes, and utensils shall be kept clean and maintained in safe condition.
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1 cases as the dishwasher was inoperable which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2022
Plan of Correction
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Licensee to ensure all equipment is in good repair at all times and repair or replace the dishwasher and submit written proof to LPA 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:Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022


LIC809 (FAS) - (06/04)
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