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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004296
Report Date: 02/02/2023
Date Signed: 02/02/2023 12:54:43 PM

Document Has Been Signed on 02/02/2023 12:54 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: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:
02/02/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Lordetha BonillaTIME COMPLETED:
01:10 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 Lordetha Bonilla, caregiver and LPA explained the nature of the visit. LPA spoke to Jon Castro, Lead Administrator and explained the nature of the visit.

The facility has five clients in care. Upon entry LPA observed there was one client in the backyard with day program coach and the rest of clients were out in the community. LPA observed there was three caregivers on site. One of the caregivers was observed to be in the kitchen doing meal preparation for clients.

During the case management visit LPA took a tour of the inside of the facility, restrooms, bedrooms, and common areas. 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-perishables food available as required by regulations. The facility stays at a comfortable temperature and the hot water temperature measured 108.8 Fahrenheit Degrees in the facility bathrooms. LPA observed hallways and walkways were free of obstruction. LPA spoke with available caregivers at the time of the visit.

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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