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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004293
Report Date: 02/02/2023
Date Signed: 02/02/2023 01:56:45 PM

Document Has Been Signed on 02/02/2023 01:56 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 & INLAND A/SC, 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:
02/02/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:13 PM
MET WITH:Rommel MendozaTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this case management visit for the purpose of conducting a health and safety check. LPA arrived at the facility was greeted and granted entry to the facility by Rommel Mendoza, Administrator and LPA explained the nature of the visit.

During the case management visit LPA accompanied by Administrator took a tour of the inside of the facility, restrooms, bedrooms, and common areas. The facility has three clients in care. LPA observed there was one client in their bedroom and the rest of the clients were out in the community. LPA observed there was two staff on site. LPA inspected food supply; adequate amount was observed to be within regulations, the food storage areas were organized. The facility has a two-day supply of perishables and seven-day supply of non-perishables food available as required by regulations. The facility has two spare refrigerators in the attached garage with food supply. LPA inspected bathrooms and the hot water temperature measured 118.4 Fahrenheit Degrees. LPA observed hallways and walkways were free of obstruction. LPA observed the outside of the facility and observed shaded seating area for clients. LPA spoke with available staff at the time of the visit. During the visit LPA observed clients coming to the facility and being checked in.

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

This report was reviewed with facility representative and a copy of this LIC809 was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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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