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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002455
Report Date: 06/07/2024
Date Signed: 06/07/2024 12:05:55 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/07/2024 12:05 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:INDEPENDENT OPTIONS INC/ANACAPA HOUSEFACILITY NUMBER:
306002455
ADMINISTRATOR/
DIRECTOR:		BUTCH MALLILLINFACILITY TYPE:
735
ADDRESS:2538 ANACAPA DRIVE #105TELEPHONE:
(714) 556-2591
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 4CENSUS: 4DATE:
06/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:41 AM
MET WITH:Nolette Untalan, Administrator and Crystal Rios, Lead Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
NARRATIVE
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 On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced Annual Required-1 year inspection visit. LPA was granted entry by Lead Direct Support Professional (DSP) Crystal Rios. Administrator (AD) Nolette Untalan arrived during today's visit.
AD Untalan indicated being present at the facility premises more than 20 hours per week AD Certificate for Nolette Untalan expires on June 20, 2025.
This is a leveI 4I Facility licensed for a capacity of four (4) clients of which two (2) clients may be non-ambulatory and providing services to Adult clients with Developmental Disabilities ages 18-59. At 9:05am, LPA Quiroz reviewed whether the following is in compliance: licensee is operating the facility within the conditions and limitations, which are specified on the license, including the capacity limitation.
At 9:15am, LPA along with (DSP) Rios conducted the tour inspection. A tour of the interior and exterior of the facility and physical plant were inspected, including but not limited to testing hot water temperature in client bedrooms and common bathrooms. Three of four client bathrooms water tested and measured between 87.0- 89.2 degrees Fahrenheit.(SEE LIC 809-D) All smoke detectors, carbon monoxide, were operational and functional. On or about 9:20am, while LPA Quiroz along with DSP Rios conducted tour of the kitchen area, LPA Quiroz observed loose kitchen cabinet next to the refrigerator and paint peeling from multiple kitchen cabinets. AD Untalan indicated facility is pending renovation of painting and cabinets, scheduled for this month. Furnishing cleanliness and state of repair, and fixtures were examined. AD Untalan agreed to purchase lamps and have maintenance come out today and repair kitchen cabinets and painting as needed. Maintenance arrived to facility on or about 11:40am(See LIC 90102-Technical Violation)
The facility is a 1 story apartment. The facility consists of: 4 client private bedrooms, 4 private restrooms for clients, visitors and staff, receiving area, living room, kitchen with dining area, laundry room area, facility carport,two small patios, one shaded backyard area with table and chairs for client and visitor enjoyment.

CONTINUED ON LIC 809-C PAGE...
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
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 06/07/2024 12:05 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 06/07/2024 at 10:53 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: INDEPENDENT OPTIONS INC/ANACAPA HOUSE
FACILITY NUMBER: 306002455

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2024
Section Cited
CCR
80088(d)(e)(1)

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80088(d)(e)(1):Furniture, Fixtures, Equipment, and Supplies:(d)The licensee shall provide lamps or lights as necessary in all rooms and other areas to ensure the comfort and safety of all persons in the facility.(e)Faucets used by clients for personal care such as shaving and CONT...
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AD Untalan agreed to have maintenance come out and repair water temperature and purchase lamps pending renovation and submit proof of repair of water temperature and lighting to CCLD by 6/14/2024.
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grooming shall deliver hot water.(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 and not more than 120 degrees F.This requirement was not
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met as evidenced by: 3 of 4 water in sinks in client bathrooms water tested and measured between 87.0- 89.2 degrees F. Lighting throughout the facility and client's bedroom was observed to be dim. This was verified with AD. This poses a potential risk to clients in care.

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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:Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024


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: INDEPENDENT OPTIONS INC/ANACAPA HOUSE
FACILITY NUMBER: 306002455
VISIT DATE: 06/07/2024
NARRATIVE
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CONTINUED...Between 10:00am-11:30am, LPA reviewed four staff records, 4 of 4 client records, 4 of 4 centrally stored medication records and 4 of 4 Personal & Incidental funds records (P&I). Staff records, centrally stored medications, and P&I records were found to be within Title 22 California Code of Regulations (CCR). LPA verified if facility is providing a comfortable temperature due to hot/cold weather condition. Facility has a working centralized heater and air conditioner to use for the cold or hot weather as needed. The temperature inside the facility was recorded to be 70 degrees Fahrenheit.
LPA reviewed facility telephone number (714)556-2591 is in working condition. Poisons, toxic substances, and other dangerous objects were noted to be secured in laundry area and under the kitchen sink not accessible to clients in care. Kitchen knives were stored and secured in kitchen cabinet, not accessible to clients in care. The outside grounds were inspected during facility tour. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. There are no exit obstructions or potential hazards. LPA observed minimal provision of sufficient lighting throughout the facility and all client's bedrooms. (SEE LIC 809-D)
AD Untalan reported offering the following indoor and outdoor activities at the facility according to weather conditions: "neighborhood walks after day program, Five Below outings, 7 Eleven walks, Family/Home visits, facility BBQs and birthday celebrations."
Two fire extinguishers observed and fully charged, last services on 2/15/2024. AD Untalan fire drills are conducted with staff and clients quarterly. Last facility fire drill scheduled to be conducted on May 5, 2024.
Plentiful basic hygiene items and linen supply were available. First Aid KIT and other aide supplies were observed to be stored in secured cabinet in dining room area.
Built in nonskid mats were observed in four of four client restrooms. Operational and functional Washer and Dryer observed in the laundry area. Facility observed to have emergency food and water and PPE readily available for clients in care.

Based on the observations made during today’s visit, Facility is being cited per Title 22 Division 6 of the California Code of Regulations. A technical violation was also assessed during today's visit.

An exit interview was conducted with AD Nolette Untalan, and a copy of this report along with the Appeal Rights, LIC 809-D page, LIC 9102-TV, LIC 858 and LIC 859 were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC809 (FAS) - (06/04)
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