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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004258
Report Date: 08/22/2022
Date Signed: 08/22/2022 02:38:49 PM

Document Has Been Signed on 08/22/2022 02:38 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:UNIQUE CARE 3FACILITY NUMBER:
306004258
ADMINISTRATOR:JOSEPH NASSIFFACILITY TYPE:
735
ADDRESS:9791 CORNWALL AVENUETELEPHONE:
(714) 714-0698
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY: 6CENSUS: 6DATE:
08/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Maria Jimenez, Yolanda BlankshipTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with Administrator Maria Jimenez and stated the purpose of this visit.

The facility is a two-story structure and licensed for six ambulatory clients. This facility offers care for the Developmentally Disabled.

At about 1:07 PM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed three clients in care and one staff member on duty. LPA toured the interior and exterior portions of the facility. There were two shared client rooms, two private client rooms and two staff rooms which were in the first and second floor. Client rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors and carbon monoxide alarms were tested to be operational. Bathroom (1) was observed to be in good repair and hot water was measured at 105.8 degrees Fahrenheit. Bathroom (2) was observed to be in good repair and hot water was measured at 105.9 degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to clients in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. Facility offers a 2-car garage mainly used as an office and for storage with an operational washer and dryer. Medications and toxins where locked and kept away from clients. Kitchen was in good repair.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2022
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: UNIQUE CARE 3
FACILITY NUMBER: 306004258
VISIT DATE: 08/22/2022
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 LPA notice PUB 475 poster in 8in x 12in. LPA informed Administrator of correct size. LPA Tapia reviewed the COVID 19 mitigation plan and the emergency disaster plan of the facility. 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.

For this visit, no deficiency was noted in areas observed and no advisory was issued.

LPA Tapia conducted an exit interview with Administrator Maria Jimenez and a copy of this report was explained and left in the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
LIC809 (FAS) - (06/04)
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