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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001989
Report Date: 06/08/2023
Date Signed: 06/08/2023 01:56:53 PM

Document Has Been Signed on 06/08/2023 01:56 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: 35DATE:
06/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:MIchelle DomingoTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit for the purpose of conducting a Required - 1 Year evaluation, in conjunction with a Case Management visit on today's date. Administrator Michelle Domingo accompanied LPA Martinez on a tour of the interior and exterior of the facility.

LPA Martinez reviewed Infection Control requirements. LPA Martinez reviewed facility telephone; provision of sufficient lighting; exit obstructions, if any; and potential hazards. Facility currently has no non ambulatory clients. Basic hygiene items, linen supply, furnishing cleanliness and state of repair of plumbing fixtures were examined. Knives and toxics were properly secured in the kitchen, storage room, and laundry room. Six client and two staff records were reviewed today. Six clients and two staff were interviewed as well. Administrator Certification for Michelle Domingo expires 10/9/2023. HIV training is up-to-date. All facility staff or other individuals who require Criminal Record Clearances have received them prior to working in the facility. Staff has current First Aid Certification. Reviewed two day supply of perishable and seven day supply of non-perishable foods which was found to be adequate. Sanitation of food service area; menus available for review; and modified diets provided as prescribed. Hot water temperature in client bathrooms was within regulatory requirements. Smoke detectors are hardwired and carbon monoxide detectors are in place and tested by outside agency on a quarterly basis. Fire extinguishers were serviced, mounted, and ready for use. Emergency drills are conducted monthly with the most current emergency evacuation drill conducted on 05/03/2023. Documentation was reviewed. Restricted Health Care Plan Approval for Diabetes is on file. None are currently using insulin injections. The clients P&I records were reviewed, LPA observed that an individual log is maintained for each client. All monies are accounted for and logs were kept to date. There is a shaded area with tables and benches for clients and visitors use.

Based on observations made, no deficiencies were observed at this time in the areas evaluated. Copy of this report will be sent to email on file.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2023
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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