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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001101
Report Date: 03/29/2022
Date Signed: 03/29/2022 01:11:32 PM

Document Has Been Signed on 03/29/2022 01:11 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:SINGH'S FAMILY CARE HOMEFACILITY NUMBER:
306001101
ADMINISTRATOR:GILBERT SINGHFACILITY TYPE:
735
ADDRESS:16151 MT. GUSTINTELEPHONE:
(714) 839-7134
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 4DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Gilbert SinghTIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPAs), Jessica Cho and Joseph Alejandre, made an unannounced visit to conduct the required annual inspection (mitigation). LPAs were greeted and granted entry by Administrator Gilbert Singh. Administrator Certification expires on 3/30/2023. Facility is a two story home with 6 bedrooms and 3 full bathrooms with a living room, family room, kitchen, and a multi-functional room. The fireplace in the family room is screened. LPAs and Administrator toured the facility. LPAs did not observe obstacles or hazards on the first floor of the facility. Smoke/carbon monoxide detectors tested operational. LPAs observed medications and sharp objects were kept locked in a closet. LPAs inspected the garage. LPAs observed use of storage of supplies and the washer and dryer were located in the garage. LPAs observed cleaning supplies kept locked in a cabinet in the garage. LPAs toured the second floor which has two bathrooms and five bedrooms. There are a total of six bedrooms which one of the bedroom is on the first floor next to the living room. Three of the bedrooms are for the clients and one of which is shared. All the bedrooms were clean and organized and had the required furnishings and linens. No obstacles or hazards observed on the second floor. The water temperature in bathroom #1 measured 114.2 degrees Fahrenheit and bathroom #2 measured at 110 degrees Fahrenheit. The backyard had the required covered patio with a place to sit under sufficient shading. No obstacles or hazards were observed in the backyard. The side gate was self-latching and operational. LPAs observed a two day perishable and a seven day non-perishable food items. Knives and medications were locked in the closet by the kitchen.

Facility has a mitigation plan that is pending approval. No deficiencies observed during the visit. No deficiencies are being cited as a result of this visit. Exit interview was conducted and a copy of the report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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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