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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002360
Report Date: 02/22/2024
Date Signed: 02/22/2024 01:31:39 PM

Document Has Been Signed on 02/22/2024 01:31 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:PUNZALAN HOMEFACILITY NUMBER:
306002360
ADMINISTRATOR:ED & LINDA PUNZALANFACILITY TYPE:
735
ADDRESS:1627 W. CATHERINE DRIVETELEPHONE:
(714) 535-2407
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 6DATE:
02/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jandarlene Anteza, Linda PunzalanTIME COMPLETED:
01:45 PM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Staff #1 (S1) Jandarlene Anteza and discussed the purpose of the inspection. Administrator (AD) Linda Punzalan arrived during the inspection.

LPA reviewed Infection Control requirements. At about 11:45AM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure: facility is a 6-bedroom, 3-bathroom, one-story house with attached garage that is being used for storage. There is a back yard with a patio cover for the clients. LPA observed 3 staff and 3 clients present at the facility. Client Bedrooms: the 6 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 114.2 and 119 degrees F in the 3 client bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 12:30PM, LPA reviewed 6 client files and 3 staff files, interviewed 3 clients and 3 staff, inspected medications for 6 clients, and inspected client money and ledgers for 6 clients. During the inspection, LPA and AD observed the following: based on observation, the licensee had a bed in a room marked as a garage on the floor plan. AD stated that no one lives in that room and that it is used for storage. LPA observed no evidence that anyone was currently living in the room and did observe some evidence that it was used for storage, but observed evidence that it may have been used as a bedroom in the past. The licensee removed the bed during the inspection and LPA confirmed.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024
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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Document Has Been Signed on 02/22/2024 01:31 PM - It Cannot Be Edited


Created By: Sean Haddad On 02/22/2024 at 01:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PUNZALAN HOME
FACILITY NUMBER: 306002360

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80010(a)
Limitations on Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee had a bed in a room marked as a garage on the floor plan, which poses a potential safety risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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During the inspection, the licensee removed the bed and LPA confirmed. POC CLEARED.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024


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: PUNZALAN HOME
FACILITY NUMBER: 306002360
VISIT DATE: 02/22/2024
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Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC809 (FAS) - (06/04)
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