<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003426
Report Date: 01/22/2025
Date Signed: 01/22/2025 02:36:55 PM

Document Has Been Signed on 01/22/2025 02:36 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:SOMERSET HOME 2FACILITY NUMBER:
306003426
ADMINISTRATOR/
DIRECTOR:		LENETTE L. BELENFACILITY TYPE:
735
ADDRESS:6162 INDIANA STREETTELEPHONE:
(714) 994-1120
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 6CENSUS: 5DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Maria DiazTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On January 22nd, 2025 Licensing Program Analyst (LPA) William Vanegas made an unannounced visit for the purposes of conducting an annual visit. LPA Vanegas was greeted and granted entry by Direct Support Staff (DSP) Maria Diaz, and explained the purpose of the visit. LPA Vanegas began a tour of the facility and observed the following.

This is a one storied home with six bedrooms five of which are client rooms and one of which is a staff room. There are three bathrooms, and an attached two car garage. LPA Vanegas observed the kitchen to be clean and free of debris. LPA Vanegas observed a microwave, dishwasher, gas stove, and they all tested operational and appeared in good condition. LPA Vanegas observed a two day supply of perishable food and a seven day supply of non-perishable food. LPA Vanegas observed a sufficient amount of emergency water as well.

LPA Vanegas observed client bathrooms to be in clean and sanitary condition with no mildew or debris present. Water faucet and toilet tested operational and contained operational shower chair, grab bars, and slip resistant matts. Water tested from 115.4-116.2 degrees

LPA Vanegas observed fire extinguisher to be fully charged and up to date and smoke and carbon monoxide detectors tested operational. LPA Vanegas observed client rooms to have all the required furnishings such as a chair, night stand, lamp, bed, enough storage space to store personal items, and clean linens in good repair meaning no strains or tears.

LPA Vanegas toured the outside of the facility and observed there to be a shaded seating area and no obstructions along emergency exit route. Side doors are unlocked and self latching. Backyard is big enough to accommodate outdoor activities and is in good repair.
CONTINUED ON LIC809C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SOMERSET HOME 2
FACILITY NUMBER: 306003426
VISIT DATE: 01/22/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA Vanegas reviewed three staff records and five client records all records (Staff and Client) contained all the required documents and training necessary to complete the daily tasks at this facility. LPA Vanegas reviewed P&I with DSP Maria Diaz and Per LPA review all balances are correct and accounted for.

LPA Vanegas reviewed medications and observed them to be locked away and inaccessible to clients in care. LPA Vanegas observed all toxins and sharps to be locked away and inaccessible to clients in care. Per LPA review all medications are being given to clients in care per physicians orders.

Based on observations made during today's inspection no deficiencies will be cited per title 22 chapeter 6 of the California Code Of Regulations. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2