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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002921
Report Date: 03/14/2022
Date Signed: 03/14/2022 03:51:25 PM

Document Has Been Signed on 03/14/2022 03:51 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:SAINT NINO MANORFACILITY NUMBER:
306002921
ADMINISTRATOR:DIVINE A. OLEGARIOFACILITY TYPE:
735
ADDRESS:4110 W. ASH AVENUETELEPHONE:
(714) 879-2269
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 6CENSUS: 3DATE:
03/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Rolando OlegarioTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by Licensee Rolando Olegario, and explained the reason for the visit. LPA observed all required postings on the wall throughout the facility. Administrator Divine A. Olegario has a current administrators certificate that expires on 05/02/2022. LPA observed a screening log book, and temperature thermometer for screening clients and visitors. LPA toured the facility with Licensee Olegario. There were two clients in care at the facility, and one client arrived after the inspection. All clients were in their room or walking around the facility. LPA began the tour checking client rooms and bathrooms. Client rooms have the necessary requirements, night stand, chair, lamp and dresser. Bathrooms were operational and clean. LPA measured the bathroom water temperature at 105 degrees Fahrenheit. All medications were locked and secure in a hallway closet. In the medication closet there was a first aid kit with all required items. The facility had a two day supply of perishable food items and seven days supply of nonperishable food items. At 2:47 PM LPA observed that the stove burners would not light without assistance. LPA advised Licensee Rolando the importance of the facility to be in good repair at all times. Knives were locked a hallway closet where the extra supply of food was kept. The facility has adequate supply of PPE. LPA observed extra linen, emergency food and water supply. LPA toured the backyard and observed an exit gates on both sides of the house that were self closing and self latching. LPA observed a shaded visitation area in the backyard equipped with tables and chairs for the clients in care. There's a pool in the backyard, and it's secured by a fence that meets title 22 regulation requirements. There were two locked sheds in the backyard that are used for storage space. LPA observed the garage, and it remains locked at all times and there are clear walkways in the garage area. All smoke detectors were tested and are operational.
No deficiencies are being cited during todays visit. An exit interview conducted and a copy of the report was provided to the Licensee Rolando Olegario.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2022
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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