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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002901
Report Date: 07/17/2023
Date Signed: 07/18/2023 07:05:36 AM

Document Has Been Signed on 07/18/2023 07:05 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:NIOBE HOMEFACILITY NUMBER:
306002901
ADMINISTRATOR:LAURA L. RUBIOFACILITY TYPE:
735
ADDRESS:2166 W. NIOBE AVENUETELEPHONE:
(714) 502-0710
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 3DATE:
07/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Laura RubioTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced Required - 1 year evaluation. LPA Martinez met and was granted entry by Staff Leo Gutoman. Lead Staff Policarpio "Paul" Veliz was called to assist with the visit. Administrator (AD) Laura Rubio was notified via telephone but unable to meet with LPA. AD Rubio has an Administrator Certificate which expired on 12/23/2022. LPA spoke to AD Rubio via telephone, who stated she has a Designated Administrator Dominic Lombos and will submit documents soon. Designated Administrator Lombos arrived shortly after. Administrator Rubio arrived shortly after.

LPA Martinez reviewed whether facility is operating within capacity limitations. Lead Staff Veliz reported census is 3, 1 was present and the other 2 clients were at Program but arrived during LPA's visit.

Facility is a LeveI 4I, licensed for a capacity of 6. The facility is a 2 story home that consist of 3 shared client bedrooms (currently private), 2 staff rooms (1 upstairs), 3 bathrooms, living-room, kitchen with dining area, Office, Meeting Room and a 2 car garage that is used for storage and laundry. The backyard has a covered patio with table and chairs for clients and visitors. Washer and dryer observed to be functional and operational. LPA, along with Lead Staff Veliz conducted a tour of the inside and outside of the facility; all passageways and other areas of potential hazard were inspected. Client bedrooms were observed to be spacious and easily accommodate furnishings such as lamps, chair, dresser and a bed. One client bathroom was clean. Faucets, showers and toilets were operational in all 3 bathrooms. LPA noted couple brown chairs are broken and were removed. LPA observed some hygiene items, but is in need of toothbrushes and toothpaste for the clients. The facility has a clean supply of linen and towels for each client. Hot water temperature in client bathroom was within regulatory requirements. All toxins, sharps and disinfectants were locked in a secured hallway closet. Kitchen and dining area were inspected. Food prep area is clean and organized. Food supply meets the requirement of one (1) week supply of non-perishable and two (2) day supply of perishables.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2023
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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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: NIOBE HOME
FACILITY NUMBER: 306002901
VISIT DATE: 07/17/2023
NARRATIVE
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Facility has a working centralized heater and air conditioner to use for cold or hot weather as needed. The home is maintained at a comfortable temperature for the clients. Temperature during the visit was at 80.7 degrees F. Medication reviewed was labeled and stored and secured in a locked entryway closet. Medication appears to have been dispensed accurately.

Staff First Aid and CPR certifications, staff training and medical assessments for staff were reviewed and found to be within Title 22 California Code of Regulations (CCR). LPA reviewed 3 client files, all were found to be within Title 22 CCR and had current Individual Program Plans (IPP). The clients P&I records were reviewed, LPA observed that an individual log is maintained for each client. All monies are accounted for and logs were kept to date.

LPA observed Fire Extinguisher to be mounted and last serviced on 03/08/2023. Fire drill log reviewed, last Fire Drill was conducted on 01/10/2022. Smoke and carbon monoxide detectors were tested and found to be operational. First Aid Kit had all required elements. There are no weapons or bodies of water on the premises. Emergency supplies to be updated.

Based on the observations made during today’s visit, the following 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 of this report will be sent to the email on file.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
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Document Has Been Signed on 07/18/2023 07:05 AM - It Cannot Be Edited


Created By: Lydia Martinez On 07/17/2023 at 03:19 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: NIOBE HOME
FACILITY NUMBER: 306002901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that LPA noted a strong urine odor in client bathroom close to the kitchen, and chairs in the facility are old and broken, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2023
Plan of Correction
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Administrator agrees to ensure restroom is kept clean and odorless at all times. Administrator to replace chairs.
Type B
Section Cited
CCR
85064
All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Licensee/Administrator Rubio did not comply with the section cited above as she is not currently certified. AD certificate has been expired since December 2022, which poses a potential personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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AD Rubio provided Designation of Responsiblity (LIC308) along with other documentation to LPA Martinez to designate an active Administrator during today's visit.
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:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/18/2023 07:05 AM - It Cannot Be Edited


Created By: Lydia Martinez On 07/17/2023 at 03:52 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: NIOBE HOME
FACILITY NUMBER: 306002901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(4)(b)
Fixtures Furniture Equipment and Supplies: The sharing of towels and washcloths between clients shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and Lead Staff confirming facility ran out of paper towels which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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Administrator agrees to have paper towels at all times.
Type B
Section Cited
CCR
80020(c0(H)
Emergency fire and earthquake drills shall be conducted quarterly on each shift in accordance with existing licensing requirements, and shall include all facility staff providing resident care and supervision on each shift.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of Fire Drill log, facility failed to conduct quarterly Fire Drills. Based on log, last Fire Drill was conducted on 01/10/2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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Administrator agrees to conduct Fire Drills as required and maintain the log. Administrator will submit an updated Fire Drill log to CCLD of completed drill by 07/21/2023.
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:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023


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