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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004293
Report Date: 02/22/2023
Date Signed: 02/22/2023 04:12:54 PM

Document Has Been Signed on 02/22/2023 04:12 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:
02/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Rommel Mendoza, AdministratorTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by care staff. LPA met with Rommel Mendoza, Administrator and explained the nature of the visit.

LPA Martinez accompanied by Administrator began the tour of the inside and outside if the facility. There are three clients in care and no active covid cases in the facility. LPA observed clients in the facility at the time of visit. All clients appeared to be clean and well taken care of. There is a sign-in procedure in place at the facility. LPA observed required department postings, covid precautionary postings and hand washing sign posted in the facility. The facility has a Mitigation Plan on file with the department. Facility has the Emergency Disaster Plan in place. There is a minimum of one week of non-perishables and two days of perishables foods available. The facility has an emergency food and water supply. Facility has a secure location for medication and has a 30 day supply of medication for clients. The facility is equipped with hand hygiene, cleaning and disinfecting supplies. Personal protective equipment (PPE) supply is available at the facility. Facility has an excess supply of PPE, cleaning, disinfectant and toxins in storage unit located in the backyard. All bathrooms observed to have a supply of soap, toilet paper and paper towels. LPA toured the client’s bedrooms, all bedrooms observed to have all required components. LPA toured the outside to the facility and observed shaded seating area for clients use.
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 the Administrator and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2023
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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