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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003468
Report Date: 03/06/2023
Date Signed: 03/06/2023 01:41:38 PM

Document Has Been Signed on 03/06/2023 01:41 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: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:
03/06/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lolita Camacho, Jean CamachoTIME COMPLETED:
01:50 PM
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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 conclude the follow-up on a report that Resident #1 (R1) had recently passed away. LPA met with Staff #1 (S1) Lolita Camacho and explained the purpose of the inspection. Staff #2 (S2) Jean Camacho arrived during the inspection. Administrator (AD) Gloria Uy was not present during the inspection.

During the inspection, LPA and S1 toured the facility. LPA observed there were 3 staff present. LPA observed 3 resident present. LPA conducted health and safety checks on the 3 residents 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, the medications were properly stored, and the facility had soap and paper towels. Since the initial inspection on 01/05/23, S2 had obtained and provided to LPA a letter from the Orange County Sheriff’s Department dated 01/26/23 which states that R1 passed away from Bilateral acute bronchopneumonia and that the manner of death was “Natural – Autopsy”. Based on the information obtained, R1 passed away from natural causes.

Based on the information obtained during the investigation, 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 discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2023
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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