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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003971
Report Date: 09/01/2022
Date Signed: 09/01/2022 11:52:01 AM

Document Has Been Signed on 09/01/2022 11:52 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:NANCITA HOMEFACILITY NUMBER:
306003971
ADMINISTRATOR:AARON RESURRECCIONFACILITY TYPE:
735
ADDRESS:713 N. NANCITA STREETTELEPHONE:
(714) 220-2657
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 6DATE:
09/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Louise IgisaiarTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted and granted entry by staff. LPA met with Administrator Louise Igisaiar. Her Administrator's certificate expires 12/5/2023. Facility has 7 bedrooms, 1 room is for staff, 2 bathrooms, kitchen, dining room, living room and a 2 car garage. LPA observed the pub 475 poster in the dining room next to the door. LPA and staff toured the facility. LPA observed all client bedrooms had the required furnishings. All clients had ample storage and clean bed linens. LPA inspected the First Aid Kit, it has all the required elements. Smoke detectors/Carbon Monoxide detectors tested operational. LPA inspected the kitchen. The kitchen is clean and organized. LPA observed knives and sharp objects are stored locked under the kitchen sink. LPA did not observe any obstacles or hazards inside of the facility. The garage is used for storage. LPA observed the medications are kept locked in a storage cabinet. LPA toured the backyard. No bodies of water observed. There are two storage sheds outside. Both sheds are kept locked and used to store supplies. Both exit gates are operational. No obstacles or hazards observed in the backyard. LPA observed Covid-19 postings inside and outside of the facility. LPA consulted with the Administrator concerning continued Covid-19 mitigation procedures and reporting requirements and Administrator requirements. No deficiencies observed during the visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
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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