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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001086
Report Date: 02/25/2025
Date Signed: 02/25/2025 11:53:39 AM

Document Has Been Signed on 02/25/2025 11:53 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:DOWNIE HOMEFACILITY NUMBER:
306001086
ADMINISTRATOR/
DIRECTOR:
PLACIDA DELA CRUZFACILITY TYPE:
735
ADDRESS:12832 DOWNIE PLACETELEPHONE:
(714) 539-6601
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY: 6CENSUS: DATE:
02/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Victor Capada- Lead Staff, Administator Placida "Nida"De la Cruz TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by Lead Staff Victor Capada. Administrator (AD) Placida De la Cruz arrived shortly after.

The facility is a single 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 Mendivil observed 3 clients in the facility, the remaining 3 clients are at day program. Facility appears clean and sanitary. All clients rooms had required elements, including bed, chair, closet space and ample lighting. Facility has extra linens in the hallway closet and the garage. LPA Mendivil tested hot water temperatures in both bathrooms and they read between 106.7 degrees and 109 degrees. LPA observed medications in locked cabinet in the kitchen. 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. Exit gates are unlocked and the paths leading to them were observed to be unobstructed. LPA reviewed six of the six client files, two of the six client medication, six of six P&I records. All client files have the required documentation. LPA Mendivil reviewed four of four staff documents, per review 3 staff do not have record of TB test results. Two of the four staff do not have a signed medical assessment indicating they are in good health.

Therefore based on observations made decifiencies are being cited per California Code of Regulations Title 22. An exit interview was conducted and a copy of this report,appeal rights and LIC 858 was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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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Document Has Been Signed on 02/25/2025 11:53 AM - It Cannot Be Edited


Created By: Andrea Mendivil On 02/25/2025 at 11:11 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: DOWNIE HOME

FACILITY NUMBER: 306001086

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 02/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 4 staff which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
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AD agreed to have medical assesments conducted and completed to LPA by POC due date.
Type A
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 4 staff which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
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AD agreed to have staff take TB test and provide results to LPA by POC due date.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


LIC809 (FAS) - (06/04)
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