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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004138
Report Date: 02/27/2024
Date Signed: 02/27/2024 04:47:36 PM

Document Has Been Signed on 02/27/2024 04:47 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:SANTOS HOMEFACILITY NUMBER:
306004138
ADMINISTRATOR:CRISTINA SANTOSFACILITY TYPE:
735
ADDRESS:11731 DEBBIE LANETELEPHONE:
(714) 621-0355
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 6CENSUS: 4DATE:
02/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Martha Losoya - AdministratorTIME COMPLETED:
03:20 PM
NARRATIVE
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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 and granted entry into facility by Lead Staff Corazon Demaclid. Assistant Administrator Martha Losoya arrived toward the end of the inspection.

The facility is a one-story home with four client bedrooms, two bathrooms, kitchen, dining room, living room, two staff rooms, office, backyard and attached 2-car garage. Facility appears clean, safe and sanitary. LPA noted five clients were away at day program. All client rooms had required elements, including bed, chair, closet space and ample lighting. Facility has extra linens for clients in the hallway closet. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured at 119 degrees Fahrenheit and 119.8 degrees Fahrenheit in the bathrooms. LPA advised facility staff to maintain a water log since the hot water heater had to be adjusted during the inspection and the temperatures are close to the threshold. A technical assistance was issued. LPA observed facility has emergency food and water supply. LPA noted Fire Extinguishers were last serviced on 10/5/2023. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in cabinets in the kitchen and cabinets outside of the garage. Knives are locked up separate from toxic chemicals. Medication for each resident is kept locked in a closet in the office. The backyard has a shaded sitting/lounging area. Exit gate is unlocked. LPA observed exit gates to be unobstructed. LPA reviewed two of the four client files and three staff files. LPA also reviewed medication for two clients and P&I for all four clients. Based on record review, LPA was unable to determine if emergency disaster drills took place at the facility in 2023. A deficiency is being issued.

One deficiency and two technical assistances were issued based on today's inspection. An exit interview was conducted and a copy of this report and appeal rights was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2024
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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Document Has Been Signed on 02/27/2024 04:47 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 02/27/2024 at 02:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SANTOS HOME
FACILITY NUMBER: 306004138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above due to the fact that the facility does not have documentation showing that drills were conducted in 2023. This poses a potential safety risk to persons in care.
POC Due Date: 03/05/2024
Plan of Correction
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Assistant Administratorr stated they will send to LPA via email the missing drill log. If AAD cannot find missing drill log, AAD stated facility will hold a drill and document it in the drill log by the assigned POC due date of 3/5/2024. AAD stated they will email LPA the completed drill documentation by the assigned POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024


LIC809 (FAS) - (06/04)
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