306004379-5-16-2024-22-AS-JHAY-D5BVUN-20240516164501

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004379
Report Date: 05/16/2024
Date Signed: 05/16/2024 04:45:10 PM

Document Has Been Signed on 05/16/2024 04:45 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	MOMS AND DADS		FACILITY NUMBER:	306004379
ADMINISTRATOR:	ACE JACER EDORA TABLANG		FACILITY TYPE:	740
ADDRESS:	6177 NORSTADT WAY		TELEPHONE:	(714) 883-3140
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY:	6	CENSUS: 5	DATE:	05/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Reca Edora Yap		TIME COMPLETED:	04:55 PM

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Licensing Program Analysts (LPAs) Jerome Haley and conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA Haley was greeted and granted entry by staff and explained the reason for the visit.

During the inspection, LPA Haley observed all resident bedrooms and bathrooms. All resident bedrooms had the necessary elements and were in compliance with regulation guidelines. Hot water temperatures were measured in the range of 105.6 degrees Fahrenheit and 105.8 degrees Fahrenheit.

In the kitchen, knives and sharp objects are kept locked in a cabinet below the counter and the medications are locked in a cabinet above the counter. A perishable food supply that meets regulation requirements was observed in the refrigerator. A non-perishable food supply that meets regulation requirements was observed in the cabinets. In the dining room are two filing cabinets. One cabinet is used for resident and staff records. A first aid kit was on top of the filing cabinet with staff and resident records.

The garage is used to store miscellaneous items. Walkways were free of obstruction. There were three additional refrigerators two for staff items and one for residents. There was a washer and dryer in the garage and soaps and other cleaning supplies are locked in a cabinet. There are several boxes of diapers in the garage and emergency bags for the residents prepared and ready to go. There is a fully charged fire extinguisher mounted on the wall. Administrator Edora Yap will have the fire extinguisher serviced or replaced as the extinguisher expired in March 2023.

The backyard has a shaded patio area with a couch and a table and chairs was observed. Both side exit gates are self-closing and self-latching. There’s a shed in the backyard used to store tools.

Smoke carbon monoxide detectors tested operational.

A disaster drill was conducted March 10, 2024 and are conducted quarterly for all staff.

Continued on LIC809C

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MOMS AND DADS	FACILITY NUMBER: 306004379
	VISIT DATE: 05/16/2024

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During the inspection, LPA Haley completed the in section of the physical plant, interviewed staff, and residents. Due to time constraints the visit was ended. A continuation visit will be conducted to complete a review of staff and resident records, and a review of all resident medications. At this time there are no citations to be issued upon completion of the visit.

A technical violation will be issued as a result of the inspection of the physical plant.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC809 (FAS) - (06/04)

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