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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001101
Report Date: 01/14/2025
Date Signed: 01/14/2025 03:31:54 PM

Document Has Been Signed on 01/14/2025 03:31 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SINGH'S FAMILY CARE HOMEFACILITY NUMBER:
306001101
ADMINISTRATOR/
DIRECTOR:		GILBERT SINGHFACILITY TYPE:
735
ADDRESS:16151 MT. GUSTINTELEPHONE:
(714) 839-7134
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 4DATE:
01/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Gilbert Singh- LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On January 14, 2025 at 8:00am, Licensing Program Analysts (LPA) Eboni Bentley made an unannounced required annual inspection at this facility. LPA Bentley met with Licensee/Administrator (LI) Gilbert Singh and stated the purpose of this visit.

The facility is a two-story home, licensed for Residential Adult Care, with three client bedrooms, two client bathrooms, kitchen, dining room, living room, family room, staff office space, two staff bedrooms, one staff bathroom, backyard and attached 2-car garage.

During the visit, LPA Bentley conducted a tour of the physical plant accompanied by LI Singh and the following was observed: There were no bodies of water on the premises, all rooms were inspected, beds and furniture were available, lighting was provided in all rooms, and storage for the client's personal belongings. Additional bed linens and bath towels were available in hallway cabinets. Bathrooms were operational and water temperatures were measured. Smoke and carbon monoxide detectors were tested and operational.

All client bedrooms were clean, well-organized with all the necessary items and storage space available. The kitchen was clean and organized. All knives and sharp objects were locked in a cabinet near the kitchen. Hazardous cleaning chemicals were found locked and secure. A two-day supply of perishable food items and seven-day supply of nonperishable food items was observed in both the kitchen and garage. A fully charged fire extinguisher was found near the kitchen with the last service date of June 14, 2024.

The garage was clean, organized, and all walkways were free of clutter. The were two refrigerators with a supply of perishable items. The washer and dryer were observed to be in working condition. The backyard was clean and free of clutter and debris. A shaded patio area with tables and chairs was observed.

Continue to LIC 809-C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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 01/14/2025 03:31 PM - It Cannot Be Edited


Created By: Eboni Bentley On 01/14/2025 at 01:22 PM
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: SINGH'S FAMILY CARE HOME
FACILITY NUMBER: 306001101

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two out of two faucets in two bathrooms. the water temperature in two common client bathrooms tested at 128.3 degrees F in Bathroom 1 and 130.4 degrees F in bathroom 2, which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Licensee will obtain the correct temperature gauge and maintain a temperature log testing temperatures every two hours from 5pm on January 14, 2025 to 5pm January 15, 2025. Licensee stated they will submit water temperature logs to CCLD via email to eboni.bentley@dss.ca.gov by 5pm on POC due date of January 15, 2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Eboni Bentley
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/14/2025 03:31 PM - It Cannot Be Edited


Created By: Eboni Bentley On 01/14/2025 at 01:22 PM
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: SINGH'S FAMILY CARE HOME
FACILITY NUMBER: 306001101

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80077.3(a)(3)(C)
Care for Clients who Lack Hazard Awareness or Impluse Control
(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, which poses a potential safety risk to persons in care. LPA observed the licensee has not conducted an emergency disaster and fire drill since June 10, 2024.
POC Due Date: 01/20/2025
Plan of Correction
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Licensee states they will conducted an emergency disaster and fire drill by January 15, 2025 and will submit completed records to CCLD via email to eboni.bentley@dss.ca.gov by the POC due date of January 20, 2025.
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, which poses a potential safety risk to persons in care. LPA observed the administrators have not completed the three hour HIV and one hour TB training within the last two years.
POC Due Date: 01/20/2025
Plan of Correction
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Licensee states both administrators will complete the three hour HIV and one hour TB training and will submit completion records to CCLD via email to eboni.bentley@dss.ca.gov by the POC due date of January 20, 2025.
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Eboni Bentley
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SINGH'S FAMILY CARE HOME
FACILITY NUMBER: 306001101
VISIT DATE: 01/14/2025
NARRATIVE
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LPA Bentley observed a first aid kit with all the required elements. Facility has a sufficient amount of emergency food supply and water supply. Clients’ medication was found locked and secure and a review of the Medication and Medication Administration Record (MAR) was conducted. A review of four (4) client service files and four (4) staff personnel files was also conducted. There is a current administrator's certification on file for Gilbert Singh with an expiration date of March 30, 2025 and one for Melissa Omectin with an expiration date of June 20, 2025. The facility has liability insurance effective June 20, 2024 through June 20, 2025.


Based on the observations made during today's visit, deficiencies are being cited as per the Title 22, Division 6 Chapter 6 of the California Code of Regulations.

An exit interview conducted and a copy of the report and appeal rights were provided to Licensee Gilbert Sigh.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC809 (FAS) - (06/04)
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