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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004012
Report Date: 10/21/2022
Date Signed: 10/21/2022 04:16:22 PM

Document Has Been Signed on 10/21/2022 04:16 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:GOOD CARE HOMEFACILITY NUMBER:
306004012
ADMINISTRATOR:CRISTINA ONGFACILITY TYPE:
735
ADDRESS:8392 SAN CLEMENTE WAYTELEPHONE:
(714) 236-0506
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 4DATE:
10/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Chrisitna OngTIME COMPLETED:
04:26 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. LPA Haley was screened and temperature checked upon entering the facility. Administrator (AD) Cristina Ong was notified via telephone and arrived for the visit.

At 2:50 PM LPA Haley and AD Ong began the inspection at the entrance of the facility. There is a fully charged fire extinguisher mounted on the wall next to the front door. A screening station with hand sanitizer and screening logs was observed right next to the front door. There were four clients present during the visit. Near the front door there's a staff room that remains locked.

Clients bedrooms were clean, organized, and had all necessary requirements: night stand, chair, lamp and storage space. Client's bathroom were clean and organized. Hot water temperature was measured at 105.2 degrees Fahrenheit in bathroom #1 and 106.8 degrees Fahrenheit in bathroom #2. In the hallway closets near the client rooms, LPA observed plenty of clean linen and additional cleaning supplies.

The kitchen has an small office space set up in the corner. Client medication, and a first aid kit with all required elements is locked in a cabinet near the refrigerator. LPA Haley observed a 2 day supply of perishable items and a 7 day supply of non-perishable items. An emergency food and water supply was observed in the kitchen. There's a staff room near the kitchen that remains locked and all client and staff files are in a file cabinet in the staff room.

The backyard had clear walkways, free of tripping hazards. Both side exit gates were self closing and self latching. LPA Haley observed a shaded patio area with tables, chairs, a treadmill and stationary bike for clients to enjoy. There's a locked cabinet in the patio area with plenty of PPE supplies. Two locked storage sheds were observed in the backyard. One shed was used to store miscellaneous supplies for the facility, and the second shed was used to store tools, cleaning supplies and other items.


Continued on LIC809C Dated 10.21.22
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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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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: GOOD CARE HOME
FACILITY NUMBER: 306004012
VISIT DATE: 10/21/2022
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In the garage, the walkways were clear and free of tripping hazards. LPA Haley observed plenty of emergency water and water stored in the garage. A washer and dryer was observed, and a shelf with plenty of additional cleaning supplies.

No bodies of water were observed during today's visit. All smoke detectors were tested and are operational.

No deficiencies are being cited during todays visit. An exit interview was conducted and a copy of this report was provided to Administrator Ong.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC809 (FAS) - (06/04)
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