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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004296
Report Date: 01/17/2023
Date Signed: 01/17/2023 11:04:02 AM

Document Has Been Signed on 01/17/2023 11:04 AM - 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:PIERCE ADULT RESIDENTAL CARE HOMEFACILITY NUMBER:
306004296
ADMINISTRATOR:ROMMEL MENDOZAFACILITY TYPE:
735
ADDRESS:3112 PIERCE AVENUETELEPHONE:
(714) 556-5102
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 5DATE:
01/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rodolfo Villa
John Castro, Adminitrator		TIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Martinez and Sandra Soto, Quality Assurance Coordinator with ROCC made an unannounced Case Management visit to the facility today in conjunction with a complaint investigation. LPA was greeted by caregiver and were granted entry. LPA and Sandra Soto, Quality Assurance Coordinator with ROCC met with Rodolfo Villa, caregiver and explained the nature of the visit.

This visit is to issue a citation today while LPA Ruth Martinez and Sandra Soto, Quality Assurance Coordinator with ROCC conducted an investigation to complaint number 22-AS-20230113172052. Upon entry it was observed there was one client in living room with a caregiver, one caregiver in kitchen with a client, and one caregiver in kitchen doing meal preparation. The facility stays at a comfortable temperature, at 9:17am the hot water temperature measured 109.9 Fahrenheit Degrees in client’s bathroom. During the case management visit a tour of the inside of the facility, restrooms and common areas was completed. LPA observed that the meal prepared appeared of good quality and storage areas organized. LPA inspected food supply adequate amount was observed to be within regulations. The facility has a two-day supply of perishables and seven-day supply of non-perishable food is available as required by regulations. LPA observed hallways and walkways were free of obstruction. During the visit Sandra Soto, Quality Assurance Coordinator with ROCC requested to review the P & I monies, per caregiver the P & I monies was not at the facility and available for review.



Based on the information obtained there are deficiencies in the areas mentioned above and are noted on the attached LIC809-D form.

This report is being reviewed with facility representative and a copy of this LIC809, and LIC809-D was provided and left at facility. Appeals Rights reviewed and a copy left at facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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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Document Has Been Signed on 01/17/2023 11:04 AM - It Cannot Be Edited


Created By: Ruth Martinez On 01/17/2023 at 10:24 AM
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: PIERCE ADULT RESIDENTAL CARE HOME
FACILITY NUMBER: 306004296

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/18/2023
Section Cited
CCR
80026(h)(1)

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Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order. This requirement is not met as evidenced by: the facility does not have
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Administrator to submit a written plan on how they will ensure P&I monies is available at the facility and accessible to staff to aide in cash resources for clients by POC due date.
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P&I records for review at the facility. Facility staff indicated P&I records are maintained away from the facility. This poses a potential Health & Safety risk to clients in care.
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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:Ruth Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023


LIC809 (FAS) - (06/04)
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