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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003934
Report Date: 09/30/2024
Date Signed: 09/30/2024 11:27:52 AM

Document Has Been Signed on 09/30/2024 11:27 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CHATEAU ST. MARK HOMES 3FACILITY NUMBER:
306003934
ADMINISTRATOR/
DIRECTOR:		ANICIA LOPEZFACILITY TYPE:
735
ADDRESS:1621 S. IVANHOE STREETTELEPHONE:
(714) 758-3655
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 5DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Thu Duong - CaregiverTIME VISIT/
INSPECTION COMPLETED:
11:42 AM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted at the facility by Thu Duong, Caregiver. LPA spoke with Administrator Martin Lopez on the phone. LPA explained the purpose of the inspection. Early Maglaya, QA Manager joined the inspection as well.

The facility is one-story home with six client bedrooms, three client bathrooms, kitchen, dining room, living room, den, laundry room, office, staff room, attached 2-car garage and backyard. LPA observed unused appliances in the backyard. QA Manager stated the facility is in the process of making arrangements to remove appliances.


Facility appears clean, safe and sanitary. LPA observed the facility has the necessary postings posted on the walls. All client rooms had the required elements, including bed, chair, closet space and ample lighting.
Facility has extra linens and hygiene supplies for residents in hallway cabinets. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured between 105 and 120 degrees F. LPA observed facility has emergency food and water supply. LPA observed the fire extinguisher was serviced on 3/21/2024 according to the attached service tag. Smoke/Carbon Monoxide detector was tested and noted as operational. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in the kitchen, garage and laundry room. Knives are locked up separate from toxic chemicals. Medication for each resident is kept locked in a cabinet in a hallway near the kitchen. Exit gate is unlocked. LPA observed exit gates to be unobstructed. LPA reviewed three client files and three staff files. LPA also reviewed medication and P&I for three residents. LPA interviewed one staff and one client.

Based on today's inspection, no deficiency is being issued. An exit interview was conducted and a copy of this report were provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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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