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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004196
Report Date: 07/03/2024
Date Signed: 07/03/2024 03:16:43 PM

Document Has Been Signed on 07/03/2024 03:16 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PLEASANT CARE HOME, THEFACILITY NUMBER:
306004196
ADMINISTRATOR/
DIRECTOR:
LOMBOS, DOMINIC L.FACILITY TYPE:
735
ADDRESS:10220 CARLOTTA AVENUETELEPHONE:
(714) 235-4865
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 2DATE:
07/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Dominic LombosTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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Licensing Program Analysts (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA Haley was greeted and granted entry by staff and explained the reason for the visit. Staff contacted Administrator Dominic Lombos who arrived a short time later and was present for the remainder of the of the visit.

During the inspection, LPA Haley observed all client bedrooms and bathrooms. All client bedrooms had the necessary elements and were in compliance with regulation guidelines.

Client bathrooms were in compliance with regulation guidelines. Hot water temperatures were measured in the range of 108.2 degrees Fahrenheit and 109.2 degrees Fahrenheit. All grab bars were tightly secured to the wall.

In the kitchen, knives and sharp objects are locked in a drawer. The stove was clean and operational. A perishable food supply that meets regulation requirements was observed in the refrigerator and a non-perishable food supply that meets regulation requirements was observed in a cabinet above the kitchen counter. There’s an area next to the kitchen with a washer and dryer and used as a laundry area. In the dining room there’s a locked filing cabinet with client medications and a first aid kit. Staff and client files are kept locked in a hallway closet.

The garage was free of clutter, and walkways were free of obstruction. There’s several items in the garage including two treadmills, an exercise bike, mattresses, and chairs. There’s cleaning supplies, and an additional supply of water in the garage. A refrigerator with an additional supply of food items was observed.

The backyard was clean, organized, and walkways were free of obstruction. A shaded patio area with a table and chairs was observed. There’s two locked sheds in the backyard. The larger shed is used for storage of miscellaneous items and the smaller shed is used to store gardening tools.

Continued on LIC809C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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 3
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: PLEASANT CARE HOME, THE
FACILITY NUMBER: 306004196
VISIT DATE: 07/03/2024
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During the visit a staff record review was completed for 3 staff members including Administrator Lombos, 4 of 4 client medications were reviewed, and all 4 client files were reviewed.

Smoke detectors, and carbon monoxide detectors tested operational. A fully charged fire extinguisher was observed mounted on a wall in between the kitchen and living room area.

An emergency evacuation drill was conducted March 20, 2024, and will continue to be conducted quarterly for all staff on each shift.

No deficiencies will be cited during today’s visit. A Technical Violation will be given for a few minor repairs/replacements that were observed during the inspection.

An exit interview was conducted, and a copy of this report was provided to Administrator Lombos.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC809 (FAS) - (06/04)
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