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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001297
Report Date: 03/20/2023
Date Signed: 03/20/2023 12:31:45 PM

Document Has Been Signed on 03/20/2023 12:31 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 & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:DISTOR'S RESIDENTIAL CAREFACILITY NUMBER:
306001297
ADMINISTRATOR:LORI J. DISTORFACILITY TYPE:
735
ADDRESS:22845 WILLARD AVETELEPHONE:
(949) 472-2062
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 4DATE:
03/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Pelagia SangerTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility was greeted and granted entry by staff and explained the nature of the visit. Four clients reside at this facility and LPA was informed that all clients were out in the community.

At 9:30am LPA began the tour of the inside and outside of the facility. LPA observed a sign-in procedure in place and LPA was check in with temperature checks. LPA observed required Department postings throughout the facility. LPA observed that the facility stays within the capacity limitations. There is a minimum of one week of non-perishables food and two days of perishables foods available. There is additional food storage in attached garage in refrigerator. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked underneath kitchen sink and locked in garage inaccessible to clients. The facility is maintained at a comfortable temperature. At 10:10am LPA measured the hot water temperature which measured 106.7 Fahrenheit Degrees. All bathrooms observed to have a supply of soap, toilet paper and paper towels. The facility provides personal hygiene items for clients use. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. The facility has an available a clean supply of linens. LPA inspected client’s bedrooms which had sufficient lighting to ensure the safety and comfort of each client. Storage space is provided for clients in their bedroom. LPA inspected that medication are centrally stored in a safe locked storage in med cart. LPA reviewed medication and observed medication was labeled and store inaccessible to clients in care. LPA observed the outside of the parameters of facility and observed outdoor passageways are free of obstruction. LPA observed there is shaded seating for clients use. Smoke detectors and alarms were tested and found to be operational. During the inspection LPA reviewed three staff records, four client records

Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: DISTOR'S RESIDENTIAL CARE
FACILITY NUMBER: 306001297
VISIT DATE: 03/20/2023
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and client’s P&I records. Each client balance matched with the ledger account and the funds were accurate. All employees have a criminal record clearance. During the inspection LPA spoke to available staff.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the facility representative and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
LIC809 (FAS) - (06/04)
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