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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004293
Report Date: 04/27/2023
Date Signed: 04/27/2023 12:09:04 PM

Document Has Been Signed on 04/27/2023 12:09 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:
04/27/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Arjhun Garcia- StaffTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility for a plan of correction (POC) in conjunction to complaint: 22-AS-20230329165330 based upon the deficiencies cited on the LIC9099-D dated for 04/06/2023.

LPA was greeted and granted entry by staff on duty (S1) Arjhun Garcia and stated the purpose of the visit.

For today's visit, there are a total of 3 clients in care, of which all 3 clients were attending Day Program.

On 04/06/23, licensee failed to ensure that planned recreational activities...are provided for the clients...

*Deficiency cited under Title 22 Regulation 85079(a)(1-2) pertaining to Activities has been CLEARED.

Facility provided LPA with proof of understanding via email regarding the regulation cited, revised the facility activity schedule for staff to adhere to, and purchased activity supplies.

During this visit, LPA observed that facility now has activities available such as: board games, card games, arts and crafts, indoor games, and sports balls (football, and soccer) for clients in care to utilize.

For this visit, no citations were issued.

An exit interview was conducted with S1 and a copy of this report, and cleared POC letter was provided and explained to S1.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
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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