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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002361
Report Date: 02/03/2025
Date Signed: 02/03/2025 04:52:34 PM

Document Has Been Signed on 02/03/2025 04:52 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:PUNZALAN HOMES INCFACILITY NUMBER:
306002361
ADMINISTRATOR/
DIRECTOR:		ERLINDA S. PUNZALANFACILITY TYPE:
735
ADDRESS:2655 W. ROME AVENUETELEPHONE:
(714) 821-5677
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 6DATE:
02/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Melissa PunzalanTIME VISIT/
INSPECTION COMPLETED:
05:05 PM
NARRATIVE
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On this day Licensing Program Analysts (LPAs) Rose Ruppert and Fred Arias made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 ambulatory clients. The facility currently has 6 clients. AD Punzalan has a valid certificate that expires on 9/7/2026. AD provided updated liability insurance that expires on 6/1/2025.

LPAs along with House Manager Anicia Lorenzo toured the facility at 2:00 PM. LPAs toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 6 client bedrooms, living room, dining room, and kitchen as well as 3 bathrooms. 4 out of 6 client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. 2 client bedrooms did not have required furniture due to their Individualized Program Plans. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 109.9 degrees F and 111.9 degrees F in all bathrooms. Client bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. LPAs toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Microwave was not operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPAs reviewed the emergency disaster plan and infection control plan and the plans were complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 12/11/2024. Outside grounds were toured. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of outings, sports and exercise. There is shaded outdoor seating for clients. Exit gates are unlocked and operational. LPAs observed the emergency water supply. LPAs reviewed 6 client files and 3 staff files.
CONTINUED ON LIC 809C DATED 2/3/2025.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2025
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 02/03/2025 04:52 PM - It Cannot Be Edited


Created By: Fred Arias On 02/03/2025 at 04:02 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 HOMES INC
FACILITY NUMBER: 306002361

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, 2 out of 3 medication cabinet locks housing medication were not functional which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/04/2025
Plan of Correction
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Medications will be moved to locked storage space in the facility. Facility to repair or replace medication cabinets soon thereafter.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Fred Arias
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/11/2025 01:32 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/11/2025 01:06 PM


Created By: RoseMarie Ruppert On 02/03/2025 at 04:02 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PUNZALAN HOMES INC
FACILITY NUMBER: 306002361

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)(C)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA records review, one PRN was administered and not documented or recorded which poses a potential health and safety risk to persons in care.
POC Due Date: 02/18/2025
Plan of Correction
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LPA requested staff in-service training on medication and PRN administration and documentation. LPA has requested in-service training to be emailed by POC date.
***** This is an amended report*****
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:Alisa Ortiz
LICENSING EVALUATOR NAME:RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025


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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PUNZALAN HOMES INC
FACILITY NUMBER: 306002361
VISIT DATE: 02/03/2025
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All client files contained required documentation including admission agreements, physician reports, and resident appraisals. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPAs reviewed medication storage and administration. Medications were found to be stored in 2 out 3 cabinets with locks that were non-operational. PRN medications were not fully available for 6 out of 6 clients. One PRN was administered to one client without documenting usage.

Based on the observations made during today’s visit, 2 deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC809 (FAS) - (06/04)
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