306004258-8-12-2024-22-AS-MTEA-D83QP9-20240812122022

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004258
Report Date: 08/12/2024
Date Signed: 08/12/2024 12:20:51 PM

Document Has Been Signed on 08/12/2024 12:20 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:	UNIQUE CARE 3		FACILITY NUMBER:	306004258
ADMINISTRATOR/ DIRECTOR:	JOSEPH NASSIF		FACILITY TYPE:	735
ADDRESS:	9791 CORNWALL AVENUE		TELEPHONE:	(714) 714-0698
CITY:	WESTMINSTER	STATE: CA	ZIP CODE:	92683
CAPACITY: 6		CENSUS: 6	DATE:	08/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:15 AM
MET WITH:	Maria Jimenez		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by Administrator (AD) Maria Jimenez. The facility is licensed for 6 ambulatory clients. Currently there are 6 clients living here during today's visit.

At 8:25 AM, LPA Tea reviewed six client files and two staff files. Client files and staff files contained all required documentation except one minor issue, there are no client admission agreements that meets Title 22. Client records contain Orange County Regional Center admission agreements. LPA advised AD to draft admission agreements based on Title 22. The administrator certificate expires on November 22, 2024.

LPA Tea along with the administrator toured the facility at 9:45 AM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a two-story home with four client bedrooms, two staff rooms, and three bathrooms. The facility has a kitchen, dining room, and living room with an attached garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured between 106.8 F degrees and 110.8 F degrees. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. LPA also observed toxin substances to be secured and locked and inaccessible to clients in a storage closet in the garage.

Continuation of annual report on LIC809C

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

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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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: UNIQUE CARE 3	FACILITY NUMBER: 306004258
	VISIT DATE: 08/12/2024

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Fire extinguishers are fully charged throughout the facility. The facility’s last fire drill was conducted on August 6, 2024. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade. LPA observed emergency supplies, food, and water in the garage and in the front entryway closet. LPA Tea observed clients leaving for their day programs and doctor appointment. The staff provide activities based on client’s personal preference such as puzzles and art coloring. Occasionally after dinner they would go on walks around the neighborhood and to the nearby park.

At 10:19 AM LPA reviewed medication storage and administration. Medications are stored in locked carts in each residential building. Medications are being administered per physician order. P&I Funds were checked and meet department standards. LPA interviewed clients regarding their quality of care and spoke to staff present regarding care provided.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with administrator Maria Jimenez and a copy of this report LIC809, 809-C, LIC858, LIC859, and LIC9102TV was read and provided to the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

LIC809 (FAS) - (06/04)

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