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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003897
Report Date: 05/20/2024
Date Signed: 05/20/2024 05:10:28 PM

Document Has Been Signed on 05/20/2024 05:10 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:PUNZALAN HOMES - STONYBROOKFACILITY NUMBER:
306003897
ADMINISTRATOR/
DIRECTOR:		ED/ERLINDA PUNZALANFACILITY TYPE:
735
ADDRESS:2785 W. STONYBROOK DRIVETELEPHONE:
(714) 821-4277
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 5DATE:
05/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Ofelia Castro and Melissa PunzalanTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On May 20, 2024 at 1:25pm, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with House Manager (HM) Ofelia Castro and explained the purpose of the visit.

The facility is licensed to operate for one (1) non-ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) bedrooms, three (3) bathrooms, attached garage, living room, dining room, kitchen, and outside covered patio area.

LPA Kim toured inside and outside of the physical plant with HM Castro. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each client’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Client Room 1, Client Room 2, Client Room 3, Client Room 4, Client Room 5, and Client Room 6. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 105.6 degrees F. A comfortable temperature of 71 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. The facility has smoke detectors and carbon monoxide detectors that were operable. The facility conducted a Fire/Safety Drill on March 9, 2024. A working telephone (714-821-4277) remains available. First Aid Kit contained all the necessary elements.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PUNZALAN HOMES - STONYBROOK
FACILITY NUMBER: 306003897
VISIT DATE: 05/20/2024
NARRATIVE
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During the visit, LPA Kim observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and clients, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA Kim conducted an audit of clients #1-#5 service files, and staff #1-#5 personnel files that were all in order and complete. LPA conducted three (3) staff interviews and five (5) client interviews.

According to the California Code of Regulations (Title 22, Division 6, Chapter 1) the following deficiency has been observed and citation issued. There was no fire extinguisher at the facility.

An exit interview was conducted, and a copy of this report was provided to staff,

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/20/2024 05:10 PM - It Cannot Be Edited


Created By: Edward Kim On 05/20/2024 at 05:03 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: 05/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
80020(a)80020 (a)All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not having a fire extinguisher serviced and mounted in the facility. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2024
Plan of Correction
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Licensee states they will provide a serviced/refilled fire extinguisher or purchase a new fire extinguisher that will be mounted and not expired at the facility. The Licensee will send POC correction to CCLD via email to edward.kim@dss.ca.gov by POC due date May 21, 2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024


LIC809 (FAS) - (06/04)
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