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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001101
Report Date: 01/26/2024
Date Signed: 01/26/2024 12:41:08 PM

Document Has Been Signed on 01/26/2024 12:41 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
ORANGE COUNTY ASC, 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:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Gilbert Singh - LicenseeTIME COMPLETED:
12:55 PM
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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 Licensee Gilbert Singh.

The facility is a two-story home with three client bedrooms, two client bathrooms, kitchen, dining room, living room, family room, staff office/lounge space, two staff rooms, one staff bathroom, backyard and attached 2-car garage. LPA observed clients to be away at day program or at the facility. Facility appears clean and sanitary. All residents rooms had required elements, including bed, chair, closet space and ample lighting. Facility had extra linens for clients in the hallway closet. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water initially measured above 120 degrees Fahrenheit. After the Licensee adjusted the hot water heater, hot water measured at 118.6 degrees Fahrenheit in the upstairs bathroom and 120 degrees Fahrenheit in the downstairs bathroom. LPA is issuing a Technical Assistance to advise the facility to maintain a water log to monitor water temperatures. LPA observed facility has emergency food and water supply. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up to prevent client access. The sharps are also locked separately from the chemicals. Medication for each resident is kept locked in a closet in the living room. The backyard has one shaded seating area, a garden clients help maintain and two dogs. LPA observed exit gate to be unobstructed. LPA reviewed all four client medication, files and P&I. During medication review, LPA noted two errors in one client's Medication Administration Record (MAR). Based on interviewing Awasis Pacheco, Direct Care Staff, LPA determined the medication was properly administered, but incorrectly documented. LPA asked Licensee if he does annual staff performance reviews. Licensee stated he does not. A Technical Violation is being issued. Facility has board games, exercise equipment, electronics and participates in outings including but not limited to vacations, shopping and clients of the facility also participate in the Special Olympics.

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

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2024
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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