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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000669
Report Date: 03/07/2022
Date Signed: 03/07/2022 11:36:26 AM


Document Has Been Signed on 03/07/2022 11:36 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:OUR LADY OF SOLACE HOMEFACILITY NUMBER:
306000669
ADMINISTRATOR:LOIDA DIMATULACFACILITY TYPE:
740
ADDRESS:469 PEPPER TREE DRIVETELEPHONE:
(714) 256-1588
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:6CENSUS: 0DATE:
03/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH: Administrators (ADs) Loida Dimatulac, ang Agnes Dimatulac;TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced annual inspection to this facility. LPA met with Administrators (ADs) Loida Dimatulac, and Agnes Dimatulac; and stated the purpose of this visit.

This facility is a single level structure and licensed for six non-ambulatory and with hospice waiver for three.

About 10:05 AM , LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, there was no resident under care. ADs L. Dimatulac and A. Dimatulac assisted the LPA in touring the facility. There were three shared resident rooms. Rooms were provided with furniture in good repair, clean linens, and adequate storage space. Smoke, carbon monoxide, and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair; and provided with handrails and nonskid-floor mats. Hot water was measured at 105 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were in locked cabinets. Fire extinguisher was mounted and charged. For the exterior portion, facility had outside furniture in good repair Side exit door were self latching. LPA Marin reviewed the COVID 19 mitigation plan of the facility. Both administrator's certificates were valid until 2023.

ADs L. Dimatulac and A. Dimatulac discussed their future plans for the facility. LPA Marin discussed the California Code of Regulations (CCR) Section 87355 Criminal Record Clearance. LPA Marin reminded and both ADs agreed to inform Community Care Licensing Division Orange Office of their plans when to resume admitting residents in the facility.

For this visit, no citation was issued.

LPA Marin conducted an exit interview with ADs L. Dimatulac and A. Dimatulac. LPA left copies of this report and CCR Section 87355 in the facility
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022
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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