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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001377
Report Date: 07/18/2024
Date Signed: 07/18/2024 05:57:30 PM

Document Has Been Signed on 07/18/2024 05:57 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:HCDD - JAGUARFACILITY NUMBER:
306001377
ADMINISTRATOR/
DIRECTOR:
KIM SOUTHERNFACILITY TYPE:
735
ADDRESS:501 E. DUNTON AVE.TELEPHONE:
(714) 974-9548
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY: 4CENSUS: 4DATE:
07/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Kim SouthernTIME VISIT/
INSPECTION COMPLETED:
06:25 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator Kim Southern and explained the reason for the visit. LPA and Administrator toured the facility. Facility is a single story home with 4 bedrooms, 2 bathrooms, kitchen, dining room, living room and activity room and a 2 car garage. The garage is kept locked and used for storage. LPA and the Administrator toured the facility. LPA observed all client rooms had the required furnishings and bed linens. LPA observed extra towels and linens in the hall closet. Both bathrooms are clean and operational. Hot water measured 112.0 degrees Fahrenheit. LPA observed there is a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the kitchen is clean and organized. The fire extinguisher in the kitchen is fully charged. LPA observed the knives are kept locked under the kitchen sink. The 4 burner gas stove lights unassisted. The smoke detectors/carbon monoxide detectors tested operational. The medication is kept locked in a cabinet in the dining room. LPA inspected the first aid kit, the first aid kit had all the required elements. The living room has a fireplace. The fireplace is screened. There is a couch in front of the fireplace making it inaccessible. LPA and the Administrator toured the backyard. No bodies of water observed. There are 2 separate covered patios for sitting outside. The exit gate is operational. No obstacles or hazards observed inside or outside of the facility. LPA reviewed 4 staff files, no discrepancies observed. All staff files reviewed had current CPR/First aid training. LPA reviewed 4 client files and P & I monies. No discrepancies observed. LPA reviewed 4 client medications, no discrepancies observed. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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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