306003468-7-27-2023-22-AS-LMAZ-CU5MGU-20230727093629

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003468
Report Date: 07/26/2023
Date Signed: 07/27/2023 09:37:23 AM

Document Has Been Signed on 07/27/2023 09:37 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 HOME		FACILITY NUMBER:	306003468
ADMINISTRATOR:	GLORIA V. UY		FACILITY TYPE:	735
ADDRESS:	1440 S. EASY WAY		TELEPHONE:	(714) 778-3901
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY: 6		CENSUS: 5	DATE:	07/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Jean Camacho		TIME COMPLETED:	11:30 AM

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	Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced Required - 1 year evaluation. LPA Martinez met and was granted entry by Administrator (AD) Jean Camacho. Administrator (AD) Gloria V. Uy was notified via telephone of LPA's presence at the facility. AD Camacho has a current Administrator Certificate which expires on 06/07/2025. LPA Martinez reviewed whether facility is operating within capacity limitations. AD Camacho reported census is 5. Three clients were present during this visit. Two were at Day Program. Facility is a LeveI 3, licensed for a capacity of 6. The facility is a 1 story home that consist of 4 bedrooms, of which 1 is occupied by live-in staff, 3 bathrooms, kitchen, living-room with dining room, family room, laundry room next to kitchen, 2 car attached garage that is used for storage. The backyard has a patio cover and sofas for clients and visitors use. Washer and dryer observed. LPA, along with AD Camacho conducted a tour of the inside and outside of the facility; all passageways and other areas of potential hazard were inspected. Client bedrooms were observed to be spacious and easily accommodate furnishings such as lamps, chair, dresser and a bed. Bathrooms were clean, faucets, showers and toilets were operational. LPA observed plenty of hygiene items, such as soap, toilet paper, toothbrush, and toothpaste for the clients. The facility has a clean supply of linen and towels for each client in care. Hot water temperature in client bathroom was within regulatory requirements. Toxins and disinfectants were observed under kitchen sink and in locked entry closet. Sharps were observed in locked kitchen drawer. Kitchen and dining area were inspected. Food prep area is clean and organized. Food supply meets the requirement of one (1) week supply of non-perishable and two (2) day supply of perishables. Facility has a working centralized heater and air conditioner to use for cold or hot weather as needed. The home is maintained at a comfortable temperature for the clients. Temperature during the visit was 76 degrees F. Medication reviewed was labeled and stored and secured in a locked kitchen cabinet. Medication appears to have been dispensed accurately.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 306003468
	VISIT DATE: 07/26/2023

NARRATIVE

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Staff First Aid and CPR certifications, staff training and medical assessments for staff was reviewed and found to be within Title 22 California Code of Regulations (CCR). LPA reviewed 4 client files, all were found to be within Title 22 CCR and had current Individual Program Plans (IPP). P&I records for two clients were reviewed, LPA observed that an individual log is maintained for each client. All monies are accounted for and logs were kept to date.

LPA observed Fire Extinguisher was mounted and last serviced on 06/15/2023. Facility does not keep a Fire drill log. Smoke and carbon monoxide detectors were tested and found to be operational. First Aid Kit had all required elements. Activity Supplies were available such as music, dancing, and word search. Emergency supplies were observed in the medication cabinet and ready to go in an event of an emergency.

Based on observations made, the following deficiency was observed at this time in the areas evaluated. Copy of this report will be sent to email on file.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 07/27/2023 09:37 AM - It Cannot Be Edited

Created By: Lydia Martinez On 07/26/2023 at 10:56 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MARY'S HOME	FACILITY NUMBER: 306003468
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80023(d)

DISASTER AND MASS CASUALTY PLAN Disaster drills shall be conducted at least every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Licensee did not comply with the section cited above in AD stated she does not keep a Fire Drill log which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	AD agrees to conduct and document a drill 07/28/2023 and forward a copy of the drill sign in sheet to CCL by POC date. AD also agrees to conduct these drills as directed in the regulation and maintain documentation for records and review when requested.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Armando J Lucero

LICENSING EVALUATOR NAME:

Lydia Martinez

LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC809 (FAS) - (06/04)

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