<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004293
Report Date: 04/01/2022
Date Signed: 04/01/2022 04:46:36 PM

Document Has Been Signed on 04/01/2022 04:46 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:STEVENS ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
306004293
ADMINISTRATOR:ROMMEL MENDOZAFACILITY TYPE:
735
ADDRESS:106 W. STEVENS AVENUETELEPHONE:
(714) 662-5717
CITY:SANTA ANASTATE: CAZIP CODE:
92707
CAPACITY: 6CENSUS: 3DATE:
04/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Rommel Mendoza TIME COMPLETED:
05:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Celine De Perio and Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPAs were greeted and granted entry by staff. LPAs explained reason for visit. At 3:50pm, Rommel Mendoza, Administrator arrived at facility. Rommel Mendoza's Administrator certificate expires on 03/06/2024. Staff and LPAs toured the facility. LPAs observed all client bedrooms had the required furnishings. LPAs observed bathroom 1 and determined it was operational and clean. Hot water was measured at 105.6 degrees Fahrenheit. LPAs observed that smoke detectors around the facility were tested and were operational. LPAs observed that fire extinguisher in the dining room is fully charged and was inspected on 02/11/2022, LPAs and staff toured the garage, which is used for storage of supplies and extra food. Garage is inaccessible to clients and is locked. LPAs and staff toured the backyard and no bodies of water was observed. There is a storage shed in the backyard and is used to keep supplies. Facility has a covered patio and a seating area for clients. LPAs observed pathway leading to exit gate is free from hazards and gate is latched and is operational. LPAs and staff toured kitchen, stove lights unassisted, and observed two day perishable and seven day non-perishable food supply on hand, knives are kept locked in a kitchen drawer, cleaning supplies are also kept locked under the sink, and kitchen overall is clean. LPAs observed that fireplace is inaccessible to clients and is no longer being used. Facility medications are stored and locked in a closet. Facility has a mitigation plan that is pending approval. No deficiencies observed during this visit. No deficiencies were cited during this visit. Exit interview was conducted and copy of report was provided to Administrator.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2022
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 1