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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001086
Report Date: 01/19/2024
Date Signed: 01/19/2024 10:39:49 AM

Document Has Been Signed on 01/19/2024 10:39 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:DOWNIE HOMEFACILITY NUMBER:
306001086
ADMINISTRATOR:PLACIDA DELA CRUZFACILITY TYPE:
735
ADDRESS:12832 DOWNIE PLACETELEPHONE:
(714) 539-6601
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY: 6CENSUS: 6DATE:
01/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH:Victor Capada - AdministratorTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by Lead Staff (LS) Victor Capada

The facility is a one-story home with four resident bedrooms, two bathrooms, kitchen, dining room, living room, lounge/staff office, staff room, backyard and attached 2-car garage. LPA observed all but one resident to be away at day program. LPA interviewed the one present resident. Facility appears clean and sanitary. All residents rooms had required elements, including bed, chair, closet space and ample lighting. Facility has extra linens in the hallway closet and the garage. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water in both bathrooms measured at 120 degrees Fahrenheit. LPA issued a technical assistance, advising LS to maintain a water log since the hot water measured so close to the maximum temperature allowed. LPA observed facility has emergency food and water supply. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up. Knives and sharps are locked in drawers in the kitchen, chemicals are locked separately in the garage. Medication for each resident is kept locked in the staff office area. Exit gates are unlocked and the paths leading to them were observed to be unobstructed. LPA reviewed three of the six residents files, three of the six residents' medication, three personnel files and the P&I. Medication, files and client money appeared to be properly stored and documented. Facility has board games, exercise equipment, electronics and more for client use. Emergency contacts, Menu and Calendar are posted and available for review.

No deficiencies were noted during today's visit. An exit interview was conducted and a copy of this report was provided to the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024
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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