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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003426
Report Date: 01/30/2025
Date Signed: 01/30/2025 06:43:35 PM

Document Has Been Signed on 01/30/2025 06:43 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: 2DATE:
01/30/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:30 PM
MET WITH:Lenette BelenTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
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Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to the facility to conduct a case management to follow up on information regarding a client’s death. LPA arrived at facility was greeted and granted entry into the facility. Lenette Belen, Administrator arrived shortly after and met with LPA. LPA explained the nature of the visit.

During LPA’s visit, LPA toured the physical plant, reviewed clients file, obtained copies of pertinent documentation and conduced interview with staff regarding the death of client 1 (C1) who passed away on January 29, 2025, for further information regarding the death of and the events that led up to the death. Per Administrator, the official Death Certificate had not been issued at this time.

There was no preliminary cause of death that was determined or provided to the Administrator at the time they received the information. LPA advised Administrator to forward any copies of reports or information regarding C1’s death to LPA as soon as it is available.

Based on observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided at the time of exit.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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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