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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001212
Report Date: 06/07/2022
Date Signed: 06/07/2022 03:58:12 PM

Document Has Been Signed on 06/07/2022 03:58 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:HCDD - DIANAFACILITY NUMBER:
306001212
ADMINISTRATOR:BOYD BRADSHAWFACILITY TYPE:
735
ADDRESS:2732 E. DIANA AVENUETELEPHONE:
(714) 666-8661
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 4DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Dolores AlapatiTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility for the purpose of conducting a Required - 1 Year Annual inspection, with an emphasis on Infection Control due to the COVID-19 pandemic. LPA Martinez met with House Manager Dolores Alapati and Staff Beth Mendoza and reason for the visit was explained. House Manager Alapati confirmed there are currently no cases or exposures of COVID-19 within the facility. LPA was screened upon entry into the facility.

LPA observed the required Department posting on COVID-19 precautions at entrance of facility. There is a sign-in procedure in place and hand sanitizer for use. LPA observed that staff were wearing face masks. The facility has an approved Mitigation Plan on file with CCLD. There were four Clients present during this visit. LPA conducted a tour of the facility and made observations pertaining to the facility's Infection Control measures. LPA toured all Client rooms, all rooms were within regulations. Clients were observed clean and content during visit. All restrooms observed contained hand washing soap, toilet paper and paper towels and had the proper hand washing signs posted. Facility has operating smoke and carbon monoxide detectors. Facility noted Fire Extinguisher was last charged on 05/13/2020. LPA observed a copy of Administrators Certificate which expires on 12/23/2023. The facility was equipped with sufficient hand hygiene supplies, cleaning and disinfecting provisions. Personal Protective Equipment (PPE) supply is available. The facility monitors the clients regularly for any COVID-19 symptoms/change of condition and documents. Facility has required Emergency Disaster Plan posted, and a secured location for client's medication and files. Facility has 30 days supply of medications for the clients. LPA reviewed client files. Client IPP's, emergency contact information and Physicians reports are current.

Based on observations made during today’s inspection, the following deficiency is being cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report, along with Appeals Right with House Manager and a copy was sent to email on file.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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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Document Has Been Signed on 06/07/2022 03:58 PM - It Cannot Be Edited


Created By: Lydia Martinez On 06/07/2022 at 02:59 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: HCDD - DIANA
FACILITY NUMBER: 306001212

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation Licensee did not comply with the section cited above in that Fire Extinguisher was not serviced per regulation. LPA observed Fire Extinguisher to be last serviced on 05/13/2020. This poses an immediate health, safety and/or personal risk to the clients in care.
POC Due Date: 06/08/2022
Plan of Correction
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Facility to ensure the Fire Extinguisher is maintained annually as required. Will replace or have the Fire Extinguisher serviced by POC due date and submit proof of correction to CCLD by 06/08/2022.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022


LIC809 (FAS) - (06/04)
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