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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004296
Report Date: 01/09/2024
Date Signed: 01/09/2024 12:22:40 PM

Document Has Been Signed on 01/09/2024 12:22 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:PIERCE ADULT RESIDENTAL CARE HOMEFACILITY NUMBER:
306004296
ADMINISTRATOR:LORA MAE AQUINOFACILITY TYPE:
735
ADDRESS:3112 PIERCE AVENUETELEPHONE:
(714) 556-5102
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 3DATE:
01/09/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Lordetha BonillaTIME COMPLETED:
12:50 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, Lead Direct Care Staff and explained the nature of the visit.

The facility has three clients in care. Upon entry LPA observed there was two clients in the living room. LPA observed there was two staff on site. Caregivers was observed to be assisting clients, doing laundry and prepping food for lunch.

During the visit LPA took a tour of the inside and outside of the facility, restrooms, bedrooms, and common areas. LPA inspected facility bathrooms and hot water temperature was measured at 105.9 Fahrenheit Degrees. 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. Facility has an additional refrigerator in the garage with food storage. LPA observed hallways and walkways were free of obstruction. LPA observed a locked storage with client’s medication. LPA observed all medication was labeled and meet regulation requirements.

LPA interviewed staff and reviewed records. LPA began review of records. LPA reviewed three (3) client records. All the required documentation was present and current in client’s 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 employee records. All employees present have a criminal record clearance and are associated to this location. Records review has a current first aid certificate.

This report was reviewed with 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: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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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