306001086-4-15-2022-22-AS-ETAA-CDHUTC-20220415155143

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001086
Report Date: 04/15/2022
Date Signed: 04/15/2022 03:52:08 PM

Document Has Been Signed on 04/15/2022 03:52 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:	DOWNIE HOME		FACILITY NUMBER:	306001086
ADMINISTRATOR:	PLACIDA DELA CRUZ		FACILITY TYPE:	735
ADDRESS:	12832 DOWNIE PLACE		TELEPHONE:	(714) 539-6601
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92843
CAPACITY:	6	CENSUS: 6	DATE:	04/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:27 PM
MET WITH:	Placida Dela Cruz		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection in this facility. LPA was met AD Placida Dela Cruz and stated the purpose of this visit. The facility is a single level structure and licensed for 4 non-ambulatory of which 2 non-ambulatory and 4 ambulatory are in the facility. This facility offers Adult Residential Facility for Developmentally Disabled. About 1:27 pm, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed six clients in care and three staff members on the duty. LPA toured the interior and exterior portions of the facility. There were two private client's rooms and 2 shared client's rooms. Residents rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors and carbon monoxide were tested to be operational. LPA observed in bedroom 3 there were two pairs of scissors which were immediately removed and locked. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 110.3 degrees Fahrenheit. Bathroom( 2) was observed to be in good repair and provided with grab bars and hot water was measured at 113.7 degrees Fahrenheit. Facility met the minimum two day supply of perishable and seven day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to clients in care. Upon further review, LPA noticed three expired cans and had AD remove expired food from pantry. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was on mount and observed. For the exterior portion, facility had a locked shed which was used as storage; and grounds were free of tripping hazards. Laundry room was in good repair. Kitchen was in good repair with knifes, medication and first aid kit kept locked. Garage was in good repair with toxins and cleaning supplies kept locked and away and inaccessible to clients.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022

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: DOWNIE HOME	FACILITY NUMBER: 306001086
	VISIT DATE: 04/15/2022

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LPA Tapia reviewed the COVID 19 mitigation plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. No citation was issued. An advisory was issued today.

LPA Tapia conducted an exit interview with AD Placida Dela Cruz and copy of this report was explained and left in the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022

LIC809 (FAS) - (06/04)

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