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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004138
Report Date: 09/28/2022
Date Signed: 09/28/2022 02:16:22 PM

Document Has Been Signed on 09/28/2022 02:16 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:SANTOS HOMEFACILITY NUMBER:
306004138
ADMINISTRATOR:CRISTINA SANTOSFACILITY TYPE:
735
ADDRESS:11731 DEBBIE LANETELEPHONE:
(714) 621-0355
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 6CENSUS: 6DATE:
09/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Macorazon Demaclid, caregiver
Imelda Infante, caregiver
Martha Losoya, house manager (via phone)		TIME COMPLETED:
02:30 PM
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On 09/28/2022, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted a case management visit for the purpose of citing deficiencies to Title 22 of the California Code of Regulations.

There are currently six (6) clients in care at the facility. Clients are observed in the common areas of the facility and in their shared bedrooms and appear clean and well taken care of. The three (3) shared bedrooms include all necessary components. Shared bathrooms are clean and equipped with grab bars and slip mats.

During the tour of the physical plant conducted alongside caregiving staff, LPA observed two fire extinguishers on display in the facility. Maintenance tags for both fire extinguishers show a maintenance in June of 2021, meaning the required annual maintenance should have been conducted by June 2022 at the latest. A Type B deficiency is being cited.

Cleaning supplies are stored in two cabinets located outdoors between the kitchen and the garage. Cabinets are equipped with locks but are shown to be unlocked during the visit. Caregiving staff states that the cabinets were left open after staff conducted the facility cleaning earlier in the morning. Staff is observed locking the cabinets after LPA inquired about the unlocked cleaning supplies. A Type B citation is also issued regarding the unsecured cleaning supplies.

Finally, the training certificate for Administrator Cristina Santos is shown to have expired on 06/25/2022. A Technical Advisory notice is issued in regard to the required posting of a current and up-to-date certificate.

This report was reviewed with facility representative and a copy of the report along with appeal rights was provided and left at facility
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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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Document Has Been Signed on 09/28/2022 02:16 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 09/28/2022 at 01:38 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: 09/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2022
Section Cited
CCR
6151(e)(3)

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The California Code of Regulations Title 7 Section 6151(e)(3) indicates that: "Portable fire extinguishers shall be subjected to an annual maintenance check. "
This requirement is not met as evidenced by:

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Licensee will contract a licensed vendor to performed the required annual maintenance on the fire extinguishers present within the physical plant and provide documentation thereof to Licensing Program Analyst before the Plan of Corrections due date.
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Based on observation and record review, fire extinguisher maintenance is out of date since June 2022 which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Additionally, licensee will ensure that the two (2) non-functional smoke detectors and the carbon monoxide detector present in the hallway are either replaced or equipped with batteries before the Plan of Corrections due date.
Type B
09/12/2022
Section Cited
CCR80087(g)

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Buildings and Grounds: "Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients."
This requirement is not met as evidenced by:
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Licensee will conduct an in-service training to remind all current staff of the required secure storage of potentially dangerous substances and provide documentation of the training and atteance to Licensing Program Analyst before the Plan of Corrections due date.
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Based on observation and interview, cabinets containing cleaning supplies, detergents and other toxic substances were left unlocked after the morning cleaning which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022


LIC809 (FAS) - (06/04)
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