306001297-4-1-2024-22-AS-CDPO-D3WVHC-20240401162655

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001297
Report Date: 04/01/2024
Date Signed: 04/01/2024 04:27:31 PM

Document Has Been Signed on 04/01/2024 04:27 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:	DISTOR'S RESIDENTIAL CARE		FACILITY NUMBER:	306001297
ADMINISTRATOR:	LORI J. DISTOR		FACILITY TYPE:	735
ADDRESS:	22845 WILLARD AVE		TELEPHONE:	(949) 472-2062
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 6		CENSUS: 4	DATE:	04/01/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:47 PM
MET WITH:	Staff on Duty - Pelagic Sanger		TIME COMPLETED:	04:36 PM

NARRATIVE

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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty (S1) Pelagic Sanger. For this visit, there are a total of 4 clients in care. Facility administrator (AD) Lori Distor was unable to be present during the time of visit. The PUB475 "See Something, Say Something" poster was observed to be in the hallway. LPA observed the Administrator's Certificate for Lori Cook, which expired on 11/20/23.

LPA De Perio toured the interior and exterior portions of the facility with S1. The facility is a single level structure and is licensed for 6 clients.

LPA observed that there are a total of 4 bedrooms, of which 1 is for staff and 2 private client rooms, and 1 shared client rooms. All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards.

Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. LPA observed that there are two bathrooms in the facility, of which 1 is for staff and 1 is for clients. The restrooms were observed to be in good repair, toilets were operational. Water temperature in restrooms were measured at 109.1 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to clients in care. Fire extinguisher was charged, mounted and located in the kitchen. LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the hallway. Facility had back-up emergency food and water supply, located in the garage. LPA De Perio observed that First Aid Kit had all the required components. Medications and toxins were locked in a cabinet and is made inaccessible to clients.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2024

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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Document Has Been Signed on 04/01/2024 04:27 PM - It Cannot Be Edited

Created By: Celine DePerio On 04/01/2024 at 04:19 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: DISTOR'S RESIDENTIAL CARE	FACILITY NUMBER: 306001297
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(12)(B)1

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation inteview and record review, LPA observed the administrator certificate expired on 11/20/23, and that there were no records to show that a renewal was in process. The licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/05/2024
	Plan of Correction
1 2 3 4	As a plan of correction (POC), licensee will initate the process for the administrator certificate renewal, on or by 4/5/24.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Sheila Santos

LICENSING EVALUATOR NAME:

Celine DePerio

LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2024

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: DISTOR'S RESIDENTIAL CARE	FACILITY NUMBER: 306001297
	VISIT DATE: 04/01/2024

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For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which was self-closing and self-latching. No bodies of water were observed.

For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

LPA De Perio conducted an exit interview with S1.

A copy of this report was provided and explained.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2024

LIC809 (FAS) - (06/04)

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