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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003468
Report Date: 07/01/2024
Date Signed: 07/01/2024 11:16:12 AM

Document Has Been Signed on 07/01/2024 11:16 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MARY'S HOMEFACILITY NUMBER:
306003468
ADMINISTRATOR/
DIRECTOR:		GLORIA V. UYFACILITY TYPE:
735
ADDRESS:1440 S. EASY WAYTELEPHONE:
(714) 778-3901
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 4DATE:
07/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Jean Camacho, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Eduard Camacho, Lead Caregiver. During today’s visit, LPA met with Jean Camacho, Administrator.

The facility is a level 3 single story building with an approved fire clearance of six ambulatory only. The facility currently has a census of four clients in care.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 137.4 and 141.0 degrees Fahrenheit. Staff adjusted water temperature of water heater which was recently replaced. Signs stating Caution: Hot Water were posted in both bathrooms. All smoke detectors were operational. The fire extinguisher is charged and was serviced on June 11, 2024. The facility has not conducted a fire and disaster drill in 2024. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medication appear to be being given as prescribed.

LPA reviewed four of four staff training and fingerprint records. LPA conducted a complete review of client records. Client P&I records were reviewed and accurate. LPA interviewed alert clients regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on June 7, 2025.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Jean Camacho, Administrator and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 809-D, LIC 421-FC, LIC 9102-TV and Appeal Rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2024
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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Document Has Been Signed on 07/01/2024 11:16 AM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 07/01/2024 at 10:33 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: 07/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80020(c)
Fire Clearance
(c) A licensee of an Adult Residential Facility or Group Home utilizing secured perimeters shall conduct fire and earthquake drills pursuant to Health and Safety Code section 1531.15(h).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA file review and interview the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2024
Plan of Correction
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Administrator wil conduct a fire and disaster drill by July 6, 2024 and email documentation to LPA.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA file review and interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2024
Plan of Correction
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Administrator will conduct a drill every quarter with all staff and clients. Documentation will be provided to LPA via email.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024


LIC809 (FAS) - (06/04)
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