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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002100
Report Date: 09/12/2023
Date Signed: 09/12/2023 03:24:20 PM

Document Has Been Signed on 09/12/2023 03:24 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SOMERSET HOMEFACILITY NUMBER:
306002100
ADMINISTRATOR:LENETTE L. BELENFACILITY TYPE:
735
ADDRESS:4950 SOMERSET ST.TELEPHONE:
(714) 739-2273
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 6CENSUS: 6DATE:
09/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lynette Belen - LicenseeTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an unannounced inspection to the facility for purpose of conducting a case management. LPA arrived at the facility at 1:30 pm and was greeted and granted entry by Lorraine Monzon (Lead Staff). Lead Staff led LPA on facility tour. Designated Administrator (AD) Lynette Belen arrived at the facility at approximately 1:50pm.

LPA observed the facility to be in good running order, clean, sanitary, safe and in good repair. LPA noted the proper postings on walls. Facility had files in order and readily available for review. Medications were organized and locked.The residents were involved with various activities.

LPA answered questions the Licensee and staff had. LPA left the Licensee and staff with business cards and communicated that the facility is newly in his caseload.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2023
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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