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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003468
Report Date: 07/15/2024
Date Signed: 07/15/2024 01:28:40 PM

Document Has Been Signed on 07/15/2024 01:28 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
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:
07/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Jean Camacho, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct a Case Management visit. LPA was greeted and granted entry by Kristine Luna, Caregiver. During today’s visit, LPA met with Jean Camacho, Administrator (AD).

The purpose of today's visit is to inform the licensee that the civil penalty form, from the annual required visit on July 1, 2024, was incorrect and will not be assessed . The civil penalty was written as a Failure to Correct and should have been written as a Repeat Violation. The facility had received a deficiency on July 26, 2023 for failure to have an earthquake and fire drill.

AD Camacho submitted the plan of correction (POC) for an earthquake and fire drill on July 6, 2024 via email to LPA to review and to clear the deficiency.

An exit interview was conducted with Jean Camacho, Administrator and a copy of this report was given to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2024
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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