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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004063
Report Date: 12/21/2023
Date Signed: 12/21/2023 03:53:00 PM

Document Has Been Signed on 12/21/2023 03:53 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:DALE B&C HOMEFACILITY NUMBER:
306004063
ADMINISTRATOR:SOPHEAP THONGFACILITY TYPE:
735
ADDRESS:8562 DAVMOR AVENUETELEPHONE:
(714) 537-8718
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6CENSUS: 5DATE:
12/21/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Sopheap Thong - AdministratorTIME COMPLETED:
04:07 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility for the purpose of conducting a Plan of Correction(POC) visit to verify corrections to deficiencies issued at the 11/15/2023 Annual inspection.

Upon arriving to the facility, Administrator Sopheap Thong was on the phone while LPA began the visit. AD finished phone call. LPA explained the purpose of the visit.

Regarding the Infection Control Plan deficiency, AD presented records to LPA. Records included AD's certificate of completion for the Infection Control Plan training course, the facility's Infection Control Plan (work in progress). Regarding the disaster drill deficiency, AD presented the drill record reflecting drills conducted on 11/28/23 and 12/3/23.

Regarding client medication documentation, AD stated pharmacy would not send a copy of the second medication page because the client's psychiatrist changes doses in the client's medication frequently. AD presented a discontinue order for the medications that were not listed in the MAR during the previous inspection. LPA reviewed the client's December medication and found all current meds accounted for and properly administered/documented.

LPA also observed the following: the backyard is organized and free of debris, gnats were not visible in either bathroom, the holes in the door in bedroom one have been repaired, the floors in the clients rooms appeared clean. All clients present stated that they help out cleaning up after themselves and that the staff help as well. The facility even decided to repair and paint the outside table so clients could still use it.

Based on record review and tour, the facility has fulfilled their plan of corrections for all citations issued on 11/15/2023. AD was informed that all citations would be cleared. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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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