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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002455
Report Date: 08/09/2022
Date Signed: 08/09/2022 11:58:54 AM

Document Has Been Signed on 08/09/2022 11:58 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:INDEPENDENT OPTIONS INC/ANACAPA HOUSEFACILITY NUMBER:
306002455
ADMINISTRATOR:BUTCH MALLILLINFACILITY TYPE:
735
ADDRESS:2538 ANACAPA DRIVE #105TELEPHONE:
(714) 556-2591
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 4CENSUS: 4DATE:
08/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:37 AM
MET WITH:Butch Alvin Mallillin - AdministratorTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Independent Options Inc/Anacapa House. LPA Velazquez was allowed entry into the facility and met with Direct Support Professional (DSP) Madison Moore. Administrator Butch Alvin Mallillin arrived shortly after LPA's arrival. The purpose of today's Case Management visit was to follow-up on an Incident Report received in the Orange Regional Office on August 4, 2022 regarding Client (C) #1.


On today's visit LPA Velazquez conducted interviews with staff. LPA Velazquez along with Administrator Mallillin took a tour of C1's room. LPA Velazquez requested copies of pertinent documentation from C1's file. Administrator Butch Alvin Mallillin agrees to email the requested documents to LPA Velazquez by COB on August 11, 2022. LPA Velazquez advised Administrator Mallillin to conduct an in-service medication training with all care staff and submit proof of training to LPA Velazquez by 08/19/2022.





There were no deficiencies issued during this Case Management visit. An exit interview was conducted with Administrator Butch Alvin Mallillin and a copy of this report along with the LIC 811 were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
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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