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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004196
Report Date: 06/08/2022
Date Signed: 06/08/2022 02:42:16 PM

Document Has Been Signed on 06/08/2022 02:42 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:PLEASANT CARE HOME, THEFACILITY NUMBER:
306004196
ADMINISTRATOR:LOMBOS, DOMINIC L.FACILITY TYPE:
735
ADDRESS:10220 CARLOTTA AVENUETELEPHONE:
(714) 235-4865
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 4DATE:
06/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:29 PM
MET WITH:Dominic LombosTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced annual inspection focusing primarily on the Infection Control. LPA was greeted and granted entry by Caregiver Henry Jr Crodua. LPA stated the purpose of the visit and entered the facility after completing the Coronavirus 2019 (COVID-19) screening procedure. Upon entry, LPA observed the screening station and sign in sheet for visitors. The required Department COVID-19 precautionary signs were posted on the front door and by the entry way. The Administrator's Certificate for Dominic L. Lombos expires on 6/27/2023.

The facility is a single level structure and licensed for six ambulatory clients. This facility offers a Level 2 service. As of today, facility had four clients. LPA observed three clients using electronic devices in their respective bedrooms, and one client was lounging on the couch in the dining room.

At 1:38 pm, LPA and Caregiver Crodua toured the interior and exterior portions of the facility; and at 1:42 pm, Administrator (Admin) Dominic Lombos assisted with the tour. Facility appeared clean and sanitary in all observed areas. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide tested operational. Bathrooms observed to be in good repair; and provided with a grab bar and a non-skid floor mat. Facility had the required hand washing signs posted in all the bathrooms. Hot water measured at 113.9 degrees Fahrenheit in Bathroom #1 and 113.5 degrees Fahrenheit in Bathroom #2. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to the clients in care. The fire extinguisher was mounted and charged in the kitchen. For the exterior portion, the facility had a locked shed for storage, patio furniture under ample shading, and grounds were free of tripping hazards. The side gates were self-closing and self-latching. LPA observed the emergency disaster and evacuation plans. Facility had sufficient emergency food and water supply. The First Aid Kit had all the required components, and the facility had sufficient PPE supplies by the entry way.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PLEASANT CARE HOME, THE
FACILITY NUMBER: 306004196
VISIT DATE: 06/08/2022
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LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. Facility provides an iPAd to clients upon request.

LPA Cho reviewed the COVID 19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Dominic Lombos, and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC809 (FAS) - (06/04)
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