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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003423
Report Date: 06/06/2022
Date Signed: 06/06/2022 01:58:09 PM

Document Has Been Signed on 06/06/2022 01:58 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:FLORES ADULT RESIDENTIAL HOMEFACILITY NUMBER:
306003423
ADMINISTRATOR:ZOILA FLORESFACILITY TYPE:
735
ADDRESS:2229 N. FOREST AVENUETELEPHONE:
(714) 542-3468
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY: 6CENSUS: 4DATE:
06/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Yvette FloresTIME COMPLETED:
02:17 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Yvette Flores. LPA observed facility does not have a screening area/ sign in sheet at the entrance of the facility. LPA spoke with Administrator Zoila Flores by telephone. LPA observed a language barrier between LPA and caregiver Flores

At 1:15 PM, LPA toured the facility with Caregiver Flores and Client 1 who assisted with translation. Facility has 4 clients in care during today's visit. LPA observed clients in the facility relaxing and LPA spoke with clients. All clients appeared well taken care of. Facility appears clean and sanitary. All client's rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Rooms are single and double occupancy. Facility submitted mitigation plan to the department. LPA observed the emergency disaster plan posted in facility. Facility has ample food supplies. Smoke detectors tested operational during today's visit and fire extinguishers are fully charged. LPA observed the locked medication storage area.

Due to translation issues, LPA is unable to complete the mitigation tool or review of files. LPA to return at a later date to complete.

LPA consulted with Caregiver regarding the importance of maintaining an adequate supply of emergency food and water at all times in the facility.

Based on the observations made during today’s visit, no 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 was left at the facility An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2022
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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