306003897-6-1-2023-22-AS-SHAD-CSDTYH-20230601150845

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003897
Report Date: 06/01/2023
Date Signed: 06/01/2023 03:08:50 PM

Document Has Been Signed on 06/01/2023 03:08 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:	PUNZALAN HOMES - STONYBROOK		FACILITY NUMBER:	306003897
ADMINISTRATOR:	ED/ERLINDA PUNZALAN		FACILITY TYPE:	735
ADDRESS:	2785 W. STONYBROOK DRIVE		TELEPHONE:	(714) 821-4277
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY: 6		CENSUS: 5	DATE:	06/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Ofelia Bellen		TIME COMPLETED:	03:20 PM

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	This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad and Dwayne Mason Jr. for the purpose of conducting an Annual Inspection. LPAs met with Staff #1 (S1) Ofelia Bellen and discussed the purpose of the inspection. Administrator (AD) Melissa Tyndall arrived during the inspection. LPAs reviewed Infection Control requirements. At about 1:00PM, LPAs and S1 conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure. This is a one-story home. Facility is a 6-bedroom, 3-bathroom, one-story house with an attached garage that is being used for storage. There is a back yard with a patio cover for the clients. LPAs observed 2 staff and 5 clients present at the facility. Client Bedrooms. The 6 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms. There are no staff bedrooms. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 111.3 and 114.9 F degrees. LPAs inspected all rooms in the facility. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. LPAs 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. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked under the kitchen sink. Toxins: observed locked under the kitchen sink and in the garage. Medication cabinet is locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 1:30PM, LPAs reviewed 5 client files and 5 staff files, interviewed 5 clients and 2 staff, inspected medications for 5 clients, and inspected client money and ledgers for 5 clients.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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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Document Has Been Signed on 06/01/2023 03:08 PM - It Cannot Be Edited

Created By: Sean Haddad On 06/01/2023 at 02:38 PM

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: PUNZALAN HOMES - STONYBROOK	FACILITY NUMBER: 306003897
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85165(b)(2)

Emergency Intervention Staff Training

(b) Staff who use, participate in, approve or provide visual checks of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training and be certified for having successfully completed the training. (2) Staff shall maintain valid certification. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records and interviews, 0 out of 5 staff had current CPI training, which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/29/2023
	Plan of Correction
1 2 3 4	Licensee stated they will register staff for CPI training and submit proof to LPA by POC due date.

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:

Sean Haddad

LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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: PUNZALAN HOMES - STONYBROOK	FACILITY NUMBER: 306003897
	VISIT DATE: 06/01/2023

NARRATIVE

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During the inspection, LPAs and AD observed the following: 5 out of 5 staff did not have current CPI training.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. AD was unavailable at time of signature so S1 signed the report.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

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