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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004138
Report Date: 03/24/2025
Date Signed: 03/24/2025 04:49:35 PM

Document Has Been Signed on 03/24/2025 04:49 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SANTOS HOMEFACILITY NUMBER:
306004138
ADMINISTRATOR/
DIRECTOR:		CRISTINA SANTOSFACILITY TYPE:
735
ADDRESS:11731 DEBBIE LANETELEPHONE:
(714) 621-0355
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 6CENSUS: 6DATE:
03/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Corazon Demaclid- Lead StaffTIME VISIT/
INSPECTION COMPLETED:
05:02 PM
NARRATIVE
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Licensing Program Analysts (LPA) Nancy Guillen conducted this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted by Caregiver Juan Rabe. Lead Staff/caregiver Corazon Demaclid granted LPA entry after explaining the purpose of the visit. Administrator was not present for the inspection. LPA observed Administrator certificate is current with an expiration date of June 25, 2026. This is an Adult Residential Facility licensed for four ambulatory and two non- ambulatory. Six clients reside at this facility. LPA was informed five clients were away at their day programs. At the time of inspection there was one client present.

LPA began the tour of the inside and outside of the facility and observed the following:
This is a one story facility with four bedrooms, one of which is used for staff, two bathrooms, living room, family room, kitchen, dining room, and garage. LPA observed required department postings posted in the living room of the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishable foods and two days of perishable foods available. There is additional food storage and emergency water in the garage. The facility is maintained at a comfortable temperature. LPA observed that medication is centrally stored in a locked storage cabinet located in the living room. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care. LPA inspected the bathrooms and LPA measured the hot water temperature which measured 106.8 to 123.9 degrees Fahrenheit. All bathrooms observed to have a supply of soap, toilet paper and paper towels. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored in the garage. The facility has an available clean supply of linens located in the hallway in 3 separate cabinets/closets.

Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Nancy Guillen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2025
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 03/24/2025 04:49 PM - It Cannot Be Edited


Created By: Nancy Guillen On 03/24/2025 at 04:15 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: 03/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 3 records due to missing health screenings. 2 out of 3 records reviewed did not have negative TB results, which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/25/2025
Plan of Correction
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Lead staff stated that health screenings for all staff and TB results for Staff 1 and 3 will be sent to LPA by POC 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:Nancy Guillen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/24/2025 04:49 PM - It Cannot Be Edited


Created By: Nancy Guillen On 03/24/2025 at 04:15 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: 03/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 3 fire extinguishers which poses a poential safety risk to persons in care. Fire extinguishers were fully charged, but last inspected on 10/05/2023.
POC Due Date: 04/07/2025
Plan of Correction
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Lead staff stated fire extinguishers will be serviced and an image of the service tags will be sent to LPA by POC date.
Type B
Section Cited
CCR
80069(c)
Client Medical Assessments
(c) The medical assessment shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 6 files due to a missing medical assessment for Client 1, which poses a potential health risk to persons in care.
POC Due Date: 04/07/2025
Plan of Correction
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Caregiver/Lead Staff stated a report was done, but is not present at the facility. Client's father to send physician's report to facility. Facility to send report to LPA by POC date.
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:Nancy Guillen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SANTOS HOME
FACILITY NUMBER: 306004138
VISIT DATE: 03/24/2025
NARRATIVE
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LPA inspected client’s bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Smoke detectors and carbon monoxide detector were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways were free of obstructions. LPA observed there was a shaded seating area outdoors for client use. LPA observed three fire extinguisher with service date of October 5th, 2023 in the living room; a deficiency was cited on today’s date.

LPA reviewed six clients’ records. All the required documentation was present and current in client’s files reviewed, however Client #5 did not have a physicians report/TB results present at the facility to review; a deficiency was cited on today’s date. The facility P&I records were reviewed. LPA observed that an individual log is maintained for each client. All monies are accounted for and attached receipts for record keeping. LPA reviewed three employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate. LPA observed three out of three records reviewed did not have a health screening and two out of three records reviewed did not have TB results; a deficiency was cited on today’s date. Disaster drills are conducted quarterly with the last drill conducted on February 11th, 2025.

Based on the observation made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducte and this report was reviewed with the Lead Staff and a copy of this report, LIC 809C, LIC 809D, LIC9102 and Appeal Rights was provided and left at the facility.
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Nancy Guillen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC809 (FAS) - (06/04)
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