306004296-4-1-2024-22-AS-CDPO-D3WQUJ-20240401122849

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004296
Report Date: 04/01/2024
Date Signed: 04/01/2024 12:29:07 PM

Document Has Been Signed on 04/01/2024 12:29 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 HOME		FACILITY NUMBER:	306004296
ADMINISTRATOR:	LORA MAE AQUINO		FACILITY TYPE:	735
ADDRESS:	3112 PIERCE AVENUE		TELEPHONE:	(714) 556-5102
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY: 6		CENSUS: 3	DATE:	04/01/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:26 AM
MET WITH:	Staff on Duty - Lordetha Bonilla		TIME COMPLETED:	12:35 PM

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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty (S1) Lordetha Bonilla. During the visit, 2 staff were on duty, who contacted facility administrator (AD) Lora Aquino about visit. AD was unable to be present during time of visit, however provided consent for S1 to receive and sign report. The PUB475 "See Something, Say Something" poster was observed to be in the kitchen. LPA observed the Administrator's Certificate for Lora Aquino, which expires on 5/31/25.

LPA De Perio toured the interior and exterior portions of the facility with S1. The facility is a single level structure and is licensed for 6 clients.

LPA observed that there are a total of 5 bedrooms, of which 1 is for staff and 2 private client rooms, and 2 shared client rooms. All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards.

Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. The restrooms were observed to be in good repair, toilets were operational. Water temperature in restrooms were measured at 109.1 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to clients in care. Fire extinguisher was charged, mounted and located in the kitchen. LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the living room. Facility had back-up emergency food and water supply, located in the garage.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2024

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: PIERCE ADULT RESIDENTAL CARE HOME	FACILITY NUMBER: 306004296
	VISIT DATE: 04/01/2024

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For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which was self-closing and self-latching.
LPA De Perio observed that First Aid Kit had all the required components. Medications and toxins were locked in a cabinet and observed to be locked and inaccessible to clients. No bodies of water were observed.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

No citations were issued.

LPA De Perio conducted an exit interview with S1. A copy of this report was provided and explained.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2024

LIC809 (FAS) - (06/04)

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