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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003468
Report Date: 07/28/2022
Date Signed: 07/28/2022 11:43:52 AM

Document Has Been Signed on 07/28/2022 11:43 AM - 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:MARY'S HOMEFACILITY NUMBER:
306003468
ADMINISTRATOR:GLORIA V. UYFACILITY TYPE:
735
ADDRESS:1440 S. EASY WAYTELEPHONE:
(714) 778-3901
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 5DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Administrator, Jean CamachoTIME COMPLETED:
11:50 AM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and was granted entry into the facility by staff. LPA Tirre met with Administrator Jean Camacho and explained the reason for the visit.

During the visit LPA toured the facility with Administrator and Staff. Facility is a 5 bedroom ( 4 client bedrooms and 1 live in staff rooms) and 3 bathroom single story home. There are 5 Clients in care. During visit LPA observed 3 clients relaxing in bedrooms. All 3 clients appeared neatly groomed and well taken care of. LPA observed department postings near front entrance of facility. LPA toured all clients rooms, all rooms where within regulations. All restrooms observed contained working wash basin, soap toilet paper and paper towels. Hand washing signs were posted in each restroom.

Facility has PPE supplies. LPA observed emergency food and water supply. Facility has 2 fridges and pantry with ample food supply. Facility has required Emergency Disaster Plan posted. Facility has a secured location for Client medication and files. Facility has a secured location for sharps and toxins. Facility has supply of medications for clients. LPA reviewed Clients files during visit. 5 of 5 clients files were observed. Clients emergency contact information and Physicians reports are current. Facility has operational smoke detectors and 2 fire extinguishers fully charged and mounted. Facility has designated area for visitors.

No deficiencies observed during visit. An exit interview was conducted with Administrator and copy of report was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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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