<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001334
Report Date: 06/21/2022
Date Signed: 06/22/2022 08:27:36 AM

Document Has Been Signed on 06/22/2022 08:27 AM - 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:MARTINEZ FAMILY HOMEFACILITY NUMBER:
306001334
ADMINISTRATOR:SAUL IVAN MARTINEZ JR.FACILITY TYPE:
735
ADDRESS:1222 S ARAPAHO DRTELEPHONE:
(714) 641-8908
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY: 4CENSUS: 4DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Saul Ivan Martinez Jr.TIME COMPLETED:
02:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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. LPA Martinez met with Administrator (AD) Saul Ivan Martinez Jr. and reason for the visit was explained. AD Martinez 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 3 Clients present during this visit. Fourth client was at Program. LPA conducted a tour of the facility and made observations pertaining to the facility's Infection Control measures. LPA toured all Client bedrooms, all rooms were within regulations. Clients appeared clean and stated they were happy with staff and the facility. 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 has Fire Extinguishers which were charged. LPA observed a copy of Administrators Certificate which expires on 03/22/2024. 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, and a secured location for Client's medication and files. Facility has 30 days supply of medications for the Clients. LPA reviewed client files. Individual Program Plan, Emergency contact information and Physicians reports are current.
LPA consulted with AD on Emergency and Disaster Plan and Infection Control Plan due 06/30/2022 and provided the PIN numbers for template for the plan.
Based on observations made during today’s inspection, no deficiencies are being cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with AD Martinez and a copy was emailed during visit.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1