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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004176
Report Date: 08/24/2021
Date Signed: 08/24/2021 12:12:16 PM

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:SAM'S HOMECAREFACILITY NUMBER:
306004176
ADMINISTRATOR:JUHAYNA DIAZFACILITY TYPE:
740
ADDRESS:18900 SEABISCUIT RUNTELEPHONE:
(714) 312-0054
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 4DATE:
08/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Juhayna Diaz, AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual visit. LPA arrived at the facility was greeted and granted entry by caregiver. LPA met with Juhayna Diaz, Administrator and explained the the nature of the visit.

LPA accompanied by caregiver toured the facility. There are four residents in care and no active covid-19 cases in the facility. LPA observed one resident in living room and two residents in their bedrooms. All residents appeared clean and well taken care of. LPA observed required department posting and covid precautionary postings in the facility. All restrooms observed to have soap/sanitizer and appeared to be clean. Residents bedrooms are currently all private and appeared to be clean and sanitary with all required components. Facility is taking covid-19 precautionary measures daily. LPA observed a check in station with sanitary precaution on the main entry of the facility. LPA observed the emergency disaster and evaluation plan. LPA observed food, water as well as first aid kits in the facility. LPA observed two shaded seating areas in the backyard for residents enjoyment, area is used for outdoor visitation as well. Facility has a supply of PPE, incontinence, and cleaning supplies. Facility has completed the LIC808 Mitigation Plan and LPA Martinez reviewed/approved the plan on site.

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.

An exit interview was conducted, this report was reviewed with Administrator and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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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