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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003468
Report Date: 01/05/2023
Date Signed: 01/05/2023 09:42:16 AM

Document Has Been Signed on 01/05/2023 09:42 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: 4DATE:
01/05/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Jean CamachoTIME COMPLETED:
09:55 AM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of a health and safety check and to follow up on a report that Resident #1 (R1) had recently passed away. LPA met with Staff #1 (S1) Jean Camacho and explained the purpose of the inspection. Administrator (AD) Gloria Uy appeared via telephone.

During the inspection, LPA and S1 toured the facility. LPA observed there were 3 staff present, all wearing PPE. LPA observed 1 resident present. LPA conducted a health and safety check on the 1 resident present and confirmed they were doing well and observed no health and safety issues. LPA observed the facility to be clean and organized, and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed the electricity and water were running and the facility had soap and paper towels. LPA interviewed S1 and AD regarding R1 and requested and reviewed copies of R1’s resident file. LPA provided technical assistance regarding smoke detectors.

Facility representative was advised that at this time further investigation is required. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2023
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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