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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306004293
Report Date:
03/20/2024
Date Signed:
03/20/2024 03:44:41 PM
Document Has Been Signed on
03/20/2024 03:44 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:
STEVENS ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER:
306004293
ADMINISTRATOR:
LORA MAE AQUINO
FACILITY TYPE:
735
ADDRESS:
106 W. STEVENS AVENUE
TELEPHONE:
(714) 662-5717
CITY:
SANTA ANA
STATE:
CA
ZIP CODE:
92707
CAPACITY:
6
CENSUS:
2
DATE:
03/20/2024
TYPE OF VISIT:
Case Management - Health Checks
UNANNOUNCED
TIME BEGAN:
03:25 PM
MET WITH:
DSP, Arjhun Garcia
TIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jenifer Tirre is conducting this visit for the purpose of conducting a health and safety check. While conducting an annual inspection visit LPA arrived at the facility was greeted and granted entry by direct care staff and explained the nature of the visit.
The facility has two clients in care. Upon entry LPA observed there was one client present in the living room watching television. During the inspection visit LPA took a tour of the inside of the physical plant of the facility. LPA inspected food supply; adequate amount was observed to be within regulations. The facility has a two-day supply of perishables and seven-day supply of non-perishables food available as required by regulations. Facility has two refrigerators with ample food supply. LPA observed hallways and walkways were free of obstruction. LPA observed a locked storage with client’s medication. LPA reviewed medication and it was observed all medication was labeled and meet regulation requirements. LPA toured the outside of the facility and observed there is a covered patio with shaded seating area for the clients enjoyment.
LPA interviewed staff and reviewed records. LPA reviewed two (2) client records. All the required documentation was present and current in client’s files reviewed. The facility P&I records were reviewed and observed that an individual log is maintained for each client. All monies are accounted for and attached receipts for record keeping. LPA reviewed two(2) employee records and both employee's has a criminal record clearance and is associated to this location.
Exit interview was conduced and this report was reviewed with facility representative. A copy of this report was provided to the facility.
SUPERVISORS NAME
:
Luz Adams
LICENSING EVALUATOR NAME
:
Jenifer Tirre
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/20/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/20/2024
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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