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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000578
Report Date: 10/10/2024
Date Signed: 10/10/2024 01:22:06 PM

Document Has Been Signed on 10/10/2024 01:22 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:FORDVIEW HOMEFACILITY NUMBER:
306000578
ADMINISTRATOR/
DIRECTOR:		MARITES T. DE VERAFACILITY TYPE:
735
ADDRESS:24372 FORDVIEW STREETTELEPHONE:
(949) 916-7233
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 4DATE:
10/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Marites Ba-VeraTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analysts (LPAs) Samer Haddadin and Kevin Saborit-Guasch conducted an unannounced visit for the purpose of an annual inspection. LPAs were greeted and granted entry by Administrator (AD) Marites Ba-Vera, and LPAs explained the purpose of the inspection.

The facility is an Adult Residential Facility (ARF) and is licensed for six ambulatory clients but vendorized for four clients by the Regional Center of Orange County. Currently there are four clients in care. The facility is a two-story home which houses the family room, living room, dining room, kitchen backyard and attached two-car garage; the second floor houses the licensee’s brothers who are cleared and fingerprinted. second is not used by clients. The facility also has three client rooms in which one is a shared bedroom, and two full bathrooms in which one is being used for clients.

Facility appears clean, safe, and sanitary. All clients’ rooms had required elements, including bed, chair, closet space, and ample lighting. Facility had extra linens and hygiene supplies for all four clients. Restrooms were stocked with soap and paper towels. Hot water measured at 108.1 degrees Fahrenheit in both bathrooms. LPAs observed the facility had a two-day supply of perishables and a seven-day supply of non-perishable food was available as required by regulations. LPAs observed hallways and walkways were free of obstruction.

LPAs observed the fire extinguisher was charged based on the arrow on the extinguisher's meter pointing into the green zone. The service tag indicates the extinguisher was last serviced on April 13, 2024. Staff tested smoke and carbon monoxide detectors. LPAs observed the detectors to be operational. Chemicals and toxins are locked up in the garage using a closet. LPAs noted the facility's knives and sharps are in the kitchen secured and locked. Medication for each client is kept locked and secured from easy reach. The backyard has one shaded seating area, and the exit gate is unlocked and unobstructed. No bodies of water observed. LPAs reviewed all four clients’ files,and medications, P&I records showed cash on hand in excess of ledger amount for one client. Ledger reconciled during the visit, no further discrepancies observed.

LPAs reviewed three staff files. All files of staff and clients contained all required documentation.

CONTINUED ON FORM LIC809-C

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
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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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: FORDVIEW HOME
FACILITY NUMBER: 306000578
VISIT DATE: 10/10/2024
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CONTINUED FROM LIC809

Upon review of records, the facility is up to date with required quarterly fire drill, which was last conducted in September 10, 2024. The administrator certificate renewal has been submitted and was verified to be pending for both administrators.

No deficiencies were noted during today's inspection visit. An exit interview was conducted, and a copy of this report was provided to the facility staff.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC809 (FAS) - (06/04)
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