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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003412
Report Date: 02/14/2022
Date Signed: 02/14/2022 12:16:03 PM

Document Has Been Signed on 02/14/2022 12:16 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:CENTER CARE HOMEFACILITY NUMBER:
306003412
ADMINISTRATOR:GILBERT SINGHFACILITY TYPE:
735
ADDRESS:17135 SANTA CATHERINE STREETTELEPHONE:
(714) 588-4141
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 4DATE:
02/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH: Melissa Omectin - AdministratorTIME COMPLETED:
12:20 PM
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Licensing Program Analysts (LPAs) Patricia Velazquez and Joseph Alejandre conducted an unannounced visit to Center Care Home. The purpose of today's visit was to conduct a Required 1 Year inspection. LPAs were allowed entry into the facility and met with Administrator (AD) Melissa Omectin. The facility is licensed for 6 ambulatory clients. There are currently 4 clients living in the facility. The last emergency disaster drill was conducted on December 22, 2021.

At 10:37 AM LPAs Velazquez and Alejandre conducted a tour of the physical plant along with AD Omectin. The 2 story home consists of 5 client bedrooms and 1 staff bedroom with 3 bathrooms. The 4 clients were not present as they were participating in an activity away from the facility. Client bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each client comfortably. Client bath towels and personal hygiene supplies were adequately stocked. LPA Alejandre tested the hot water temperature in the client bathrooms and it ranged from 105.2 to 112.2 degrees Fahrenheit. Bathrooms were observed to be in good repair with non-skid surfaces present. LPAs inspected the kitchen with AD Omectin. Perishable and non-perishable food was checked and adequately stocked at the time of the visit. The fire extinguishers were fully charged. Toxins, sharps, and medications were locked and inaccessible to clients. First aid kit was checked and found to be in order. LPAs Velazquez and Alejandre along with AD Omectin observed 1 of 9 smoke alarms in the facility was operational and a client bedroom did not have a smoke alarm present in their room at the time of the visit which AD Omectin verified. The carbon monoxide detector in a hallway was also observed to be inoperable which AD Omectin verified.

LPAs Velazquez and Alejandre along with AD Omectin toured the outside grounds and no bodies of water were observed. There was shading and sufficient seating for clients. Walkways around the home were clear of hazards and the exit gates were operational. There were no security bars or weapons on the premises.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2022
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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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: CENTER CARE HOME
FACILITY NUMBER: 306003412
VISIT DATE: 02/14/2022
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No client or staff files were reviewed at the time of this visit.


Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 6.

An exit interview was conducted with Administrator Melissa Omectin and a copy of this report along with the appeal rights and LIC 9098 were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/14/2022 12:16 PM - It Cannot Be Edited


Created By: Patricia Velazquez On 02/14/2022 at 11:39 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: CENTER CARE HOME
FACILITY NUMBER: 306003412

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(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.
Deficient Practice Statement
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This requirement is not met as evidenced by: the licensee did not comply with this regulation and did not ensure all smoke detectors were in operating condition. Only 1 of 9 smoke detectors were operational and the carbon monoxide detector was inoperable. This poses an immediate risk to the health and safety of clients in care.
POC Due Date: 02/15/2022
Plan of Correction
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Licensee to repair or replace the inoperable smoke detectors throughout the facility and carbon monoxide detector and submit written proof to LPA Velazquez by 2/15/2022.
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:Sheila Santos
LICENSING EVALUATOR NAME:Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2022


LIC809 (FAS) - (06/04)
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