306004293-3-4-2025-22-AS-NGUN-DEG2FW-20250304162213

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004293
Report Date: 03/04/2025
Date Signed: 03/04/2025 04:22:30 PM

Document Has Been Signed on 03/04/2025 04:22 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/ DIRECTOR:	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:	03/04/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:42 PM
MET WITH:	Winnie Greco, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:36 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) Hanna Gough and Nancy Guillen conducted an unannounced required annual visit. LPAs were greeted by staff and granted entry after stating the purpose of the visit. Administrator (AD) Winnie Greco accompanied LPAs during the duration of the visit.

The facility is licensed for six clients, two non-ambulatory and four ambulatory. The facility currently has two clients in care.

LPAs observed that the facility is a single-story home with a two-car garage. The facility has four bedrooms, one client bathroom, three client rooms, and one live in staff bedroom with an attached bathroom. LPAs observed that the bedroom that was used for staff and was separated with permanent walls making it into two bedrooms.

LPAs conducted a tour of the facility with the administrator, and the following was observed: All rooms were inspected. LPAs observed that all bedrooms had the required components and furnishings. Clean linens were stored in a closet in the hallway. Bathrooms were operational with water temperature measuring at 117.1 Degrees Fahrenheit. LPAs toured the kitchen. LPAs observed that the sharps are locked and inaccessible to clients in care. LPAs observed that the medications are locked and stored in a closet in the entry way of the facility and inaccessible to clients in care. LPAs observed that toxic chemicals are stored and locked under the kitchen sink and inaccessible to clients in care. LPAs observed that three of the four kitchen burners are working in working order. A technical violation was given to ensure that the fourth burner gets repaired.

LPAs observed extra activity materials stored in the garage. LPAs observed a two day perishable and one week non-perishable food supply was on hand and maintained. LPAs observed the emergency food and water supply located in the garage. CONTINUED ON 809C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Nancy Guillen
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

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

Document Has Been Signed on 03/04/2025 04:22 PM - It Cannot Be Edited

Created By: Nancy Guillen On 03/04/2025 at 03:57 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: STEVENS ADULT RESIDENTIAL CARE HOME	FACILITY NUMBER: 306004293
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80020(a)

Fire Clearance

(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in one out of four bedrooms which poses an immediate safety risk to persons in care due to lack of a fire clearance and not following the facility sketch.
	POC Due Date: 03/05/2025
	Plan of Correction
1 2 3 4	Administrator stated that they will provide a written plan of correction by March 5, 2025. Administrator stated that the wall will be taken down by March 18, 2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Armando J Lucero

LICENSING EVALUATOR NAME:

Nancy Guillen

LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

LIC809 (FAS) - (06/04)

Page: 2 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: STEVENS ADULT RESIDENTIAL CARE HOME	FACILITY NUMBER: 306004293
	VISIT DATE: 03/04/2025

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
26
27
28
29
30
31
32

LPAs observed a fire extinguisher in the dining room to be fully charged with a service date of December 14, 2024.

LPAs observed the outside of the facility and found that it was free of debris and cleared of obstructions. There was a shaded seated area for clients to enjoy. LPAs observed a shed in the backyard that was used for extra storage space and is locked and inaccessible to clients in care. LPAs reviewed three staff files, no discrepancies were observed. LPAs observed two client files, no discrepancies were observed. LPAs observed all required licensing postings throughout the facility. LPAs observed the P&I log and no discrepancies were observed.

LPAs observed the First Aid Kit was complete and maintained. The last fire drill was conducted on January 1, 2025. LPAs tested the facility fire and carbon monoxide detectors and they were found to be operational. LPAs informed that licensing fees are due.

Based on the observations made during today’s inspection, a deficiency was cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Nancy Guillen
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3