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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004138
Report Date: 03/21/2022
Date Signed: 03/21/2022 01:57:18 PM

Document Has Been Signed on 03/21/2022 01:57 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:SANTOS HOMEFACILITY NUMBER:
306004138
ADMINISTRATOR:CRISTINA SANTOSFACILITY TYPE:
735
ADDRESS:11731 DEBBIE LANETELEPHONE:
(714) 621-0355
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 6CENSUS: 5DATE:
03/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:MaCorazon DemaclidTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by caregiver. LPA explained the nature of the visit to caregiver.

LPA Martinez accompanied by caregiver began the tour of the inside and outside of the facility. There are five clients in care and there are no active Covid-19 cases in the facility. LPA observed one client in the facility and remainder of clients are out in the community. Client appeared to be clean and well taken care of. LPA observed a check in station in the entry of the facility. LPA observed required department postings, Covid-19 precautionary postings in the facility as well as hand washing signs throughout the facility. All restrooms observed to have a supply of soap and appeared to be clean. LPA inspected client’s bedrooms and appeared to be clean and sanitary. All bedrooms observed to have all required components. LPA observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food and water in attached garage. LPA observed the PPE supply in the facility readily available for use. LPA toured the outside of the facility and observed seating are for client’s enjoyment. The facility has completed the LIC808 Mitigation Plan. The plan was reviewed and approved by the Department on July 26, 2021. LPA was informed that all client’s and staff have had their Covid booster shots.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the facility representative and a copy of this report was provided to the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2022
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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