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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001989
Report Date: 08/03/2022
Date Signed: 08/03/2022 03:44:29 PM

Document Has Been Signed on 08/03/2022 03:44 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:CARING VILLAGEFACILITY NUMBER:
306001989
ADMINISTRATOR:MICHELLE DOMINGOFACILITY TYPE:
735
ADDRESS:8912 W. KATELLATELEPHONE:
(714) 484-6524
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 49CENSUS: 39DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Michelle Domingo TIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with Administrator Michelle Domingo and stated the purpose of this visit.

The facility is a single level dormitory style structure and licensed for four non-ambulatory clients. This facility is an Adult Residential Facility for the Mentally Disabled.

At about 1:50 PM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed clients in the front entry of the facility. LPA toured the interior and exterior portions of the facility. There were 2 separate halls which housed male clients on one side and female clients on the other. Client rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Client rooms observed contained sinks with hand washing signs posted nearby. Administrator provided reports for fire alarms which were last tested on 05/25/2022. Carbon monoxide alarms were tested on 07/22/2022. Facility offers common restrooms with showers. Restrooms were observed to be in good repair and provided with grab bars and hot water was measured between 113.9 degrees to 114.6 degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to clients in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguishers were observed mounted. For the exterior portion, facility had a patio walkway separating the 2 hallways with outside furniture in good repair; and grounds were free of tripping hazards. Laundry room was kept locked with cleaning supplies kept locked inside the laundry room. Kitchen was in good repair and kept locked only staff are allowed inside the kitchen. LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency Disaster plan of the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CARING VILLAGE
FACILITY NUMBER: 306001989
VISIT DATE: 08/03/2022
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LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. No citation was issued. No advisory was issued today.

LPA Tapia conducted an exit interview with Administrator Michelle Domingo and a copy of this report was explained and left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC809 (FAS) - (06/04)
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