306004293-3-20-2024-22-AS-JTIE-D3JUF8-20240320153218

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004293
Report Date: 03/20/2024
Date Signed: 03/20/2024 03:32:30 PM

Document Has Been Signed on 03/20/2024 03:32 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:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Direct Service Professional Arjhun Garcia		TIME COMPLETED:	03:24 PM

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On 3/20/2024, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by Direct Service Professional and granted entry after stating the purpose of the visit. Administrator (Admin) Lora Aquino was not present to assist with the facility inspection on today's date. Administrator consented by telephone for Direct Service Professional Arjhun Garcia to sign the report on her behalf.

The facility is licensed for six (6), Two (2) non-ambulatory and four (4) ambulatory clients. Currently, facility has two clients in care. Currently, there is one client present during today’s visit.

This is a single story with a two-car garage facility. The facility has four bedrooms, three shared client rooms, one live in staff bedroom and one bathroom.

At around 9:37 AM, LPA conducted a tour of the physical plant accompanied by staff member Arjhun Garcia, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 106.3 degrees F. A comfortable temperature of 66 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient two days perishable and one week non-perishable food was maintained adequately. Facility has two fire extinguishers fully charged. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance.

CONTINUED ON 809C

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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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: 03/20/2024

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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and clients and sanitizing stations in common areas and restrooms. LPA observed the facility has supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working landline phone was operational at phone number 714-662-5717. The last fire drill was conducted on February 22, 2024. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective July 18, 2023 - July 18, 2024.

A review of two Clients (C1-C2) service files and two staff (S1-S2) personnel files revealed to be complete. The facility has the current administrator's certification on file for Lora Mae Aquino # 6059601735 - Expiration 5/31/2025.

No deficiencies during this inspection visit.

An exit interview was conducted with Staff, and a copy of the report was provided.

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

LIC809 (FAS) - (06/04)

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