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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002363
Report Date: 02/28/2022
Date Signed: 02/28/2022 11:25:35 AM

Document Has Been Signed on 02/28/2022 11:25 AM - 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 HOMES IVFACILITY NUMBER:
306002363
ADMINISTRATOR:ED & LINDA PUNZALANFACILITY TYPE:
735
ADDRESS:409 N. COLORADO STTELEPHONE:
(714) 535-2407
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 3DATE:
02/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Linda Punzalan, Isabelita SaritaTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was screened for symptoms of Covid-19 and granted entry. LPA met with staff and explained the reason for the visit. Administrator Linda Punzalan arrived at 10:30 am. LPA and staff toured the facility. Facility has 6 bedrooms, 1 is for staff and 1 is vacant. The garage is used as a staff/meeting room and for storage. LPA observed all of the client rooms had the required furnishings and were clean and organized. All smoke detectors and carbon monoxide detectors tested operational. The fireplace in the living room has a bookcase in front of that makes the fireplace inaccessible to clients. LPA inspected the kitchen. LPA observed a 2 day perishable and 7 day non-perishable food supply on hand. The stove lights unassisted. The kitchen is clean and organized. LPA observed medication is kept locked in a dining room cabinet. LPA observed all sharp objects are kept locked under the sink along with cleaning supplies. Facility has 3 bathrooms. Hot water measured from 125.0 degrees Fahrenheit to 129.0 degrees Fahrenheit. LPA toured the backyard. The shed in the backyard is kept locked and used for storage. There is a covered patio with a seating area for clients. There are 3 exercise bikes for the clients in the patio. No bodies of water observed. Both exit gates are operational. No obstacles or hazards observed. Based on the observations made during this inspection deficiencies are being cited per Title 22, Division 6 of The California code of regulations. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2022
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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Document Has Been Signed on 02/28/2022 11:25 AM - It Cannot Be Edited


Created By: Joseph Alejandre On 02/28/2022 at 10:57 AM
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 IV
FACILITY NUMBER: 306002363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
LPA measured the hot water temperature to be from 125.0 degrees Fahrenheit to 129.0 degrees Fahrenehit in all 3 bathrooms.
Deficient Practice Statement
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Based on LPA measurement of the hot water the licensee did not comply with the section cited above in 3 out of 3 bathrooms which poses an immediate health and safety risk to clients in care.
POC Due Date: 03/01/2022
Plan of Correction
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Licensee states that the hot water temperature would be adjusted and then measured to ensure the proper temperature of the hot water is between 105 and 120 degrees Fahrenheit.
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:Luz Adams
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022


LIC809 (FAS) - (06/04)
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