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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004296
Report Date: 05/05/2023
Date Signed: 05/05/2023 01:50:36 PM

Document Has Been Signed on 05/05/2023 01:50 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: 3DATE:
05/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Lordetha Bonilla, Lead Direct Care ProviderTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility was greeted and granted entry by Lordetha Bonilla, Lead Direct Care Provider and LPA explained the nature of the visit.

Three clients reside at this location. LPA was informed one client was in day program and LPA observed two clients in living room. LPA began the tour of the inside and outside of the facility. LPA observed department postings through out the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in attached garage in refrigerator. The facility is maintained at a comfortable temperature. LPA inspected that mediation are centrally stored in a safe locked storage cabinet located in kitchen. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care. LPA measured the hot water temperature which measured 105.7 Fahrenheit degrees. Facility bathroom observed to have a supply of soap, toilet paper and towels. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored and locked in garage inaccessible to clients. The facility has an available clean supply of linens. LPA inspected client’s bedrooms which has sufficient lighting to ensure the safety and comfort. Storage space is provided for clients in their bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there is shaded seating areas for client’s enjoyment. LPA observed a fire extinguisher mounted on the wall of the kitchen and garage. Fire drills conducted once a month and LPA verified last Fire Drill was conducted on 04/12/23. LPA began review of records. LPA reviewed three client records. All the required documentation was present and current in client’s


Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 306004296
VISIT DATE: 05/05/2023
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files reviewed. The facility P&I records were reviewed. LPA observed that an individual log is maintained for each client. All monies are accounted for and attached receipts for record keeping. LPA reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility.

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 facility representative 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: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC809 (FAS) - (06/04)
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