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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002901
Report Date: 07/01/2024
Date Signed: 07/01/2024 03:31:06 PM

Document Has Been Signed on 07/01/2024 03:31 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:NIOBE HOMEFACILITY NUMBER:
306002901
ADMINISTRATOR/
DIRECTOR:		LAURA L. RUBIOFACILITY TYPE:
735
ADDRESS:2166 W. NIOBE AVENUETELEPHONE:
(714) 502-0710
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 3DATE:
07/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Laura Rubio, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Policarpo "Pol" Veliz, House Manager, DSP. During today’s visit, LPA met with Laura Rubio, Administrator.

The facility is a Level 4i double story building with an approved fire clearance of five non-ambulatory and one ambulatory. The facility currently has a census of three clients in care.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two client bathrooms, and there are no auditory devices on all exits. The hot water temperature measured between 106.4 and 107.1 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on April 4, 2024. The facility’s last fire/ disaster drill was conducted on June 25, 2024. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medication appear to be being given as prescribed.

LPA reviewed three of three staff training and fingerprint records. LPA conducted a complete review of client records. LPA interviewed alert clients regarding their quality of care and spoke to staff present regarding care provided. The administrator has an expired administrator certificate from December 23, 2022.

The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Laura Rubio, Administrator and a copy of this report was given to the facility along with a copy of the LIC 809-D LIC 1902-TV, LIC 421-FC and Appeal Rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2024
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 07/01/2024 03:31 PM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 07/01/2024 at 03:04 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: 07/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) 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 LPA file review, website and telephone call to the Administrator Certification Bureau (ACB), the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. This is a repeat violation from July 17, 2023. Administrator Certificate expired on December 23, 2022.
POC Due Date: 07/08/2024
Plan of Correction
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Administrator to submit and expedite renewal application to ACB and provide proof of documentation by emailing LPA.
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: 07/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024


LIC809 (FAS) - (06/04)
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