306004379-1-31-2025-22-AS-EBEY-DDG4U2-20250131182402

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004379
Report Date: 01/31/2025
Date Signed: 01/31/2025 06:25:19 PM

Document Has Been Signed on 01/31/2025 06:25 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:	MOMS AND DADS		FACILITY NUMBER:	306004379
ADMINISTRATOR/ DIRECTOR:	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	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	01/31/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Reca Edora Yap - Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On January 31, 2025, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced, for the purpose of conducting a required one year annual visit using the CARE Inspection Tool. LPA Bentley was greeted, granted entry by staff, and explained the reason for the visit. Administrator (AD) Reca Edora Yap arrived a short time later and was present for the visit. AD Yap has an Administrator Certificate pending approval, received November 25, 2024. Additional administrators/certificates: Ace Edora Tablang expiration date September 26, 2024 and Mc Jevin Tablang expiration date June 21, 2025. Moms and Dads is a one story home with three (3) resident bedrooms, one (1) staff bedroom and two bathrooms. The facility is licensed for six (6) non-ambulatory residents, one (1) bedridden resident, with an approved hospice waiver for three (3) residents. Currently, there are four (4) residents on census of which three (3) are receiving hospice care. All four (4) residents were present during today’s visit. At 9:00AM, LPA Bentley conducted a tour of the physical plant accompanied by AD Yap and the following was observed: All resident bedrooms and bathrooms were inspected. Each bedroom had adequate lighting, furniture, bedding, storage for the residents’ personal belongings, all necessary elements present and rooms were in compliance with regulation guidelines. Additional bed linens, comforters, and bath towels were available during the visit. The kitchen was clean and organized. knives and sharp objects were kept locked in a cabinet below the counter and medications were locked in a cabinet above the counter. A two day supply of perishable food items and seven day supply of nonperishable food items was observed. CONTINUE TO 809-C PAGE

Lourdes Montoya	TELEPHONE: (714) -705-6014
Eboni Bentley	TELEPHONE: 714-552-7883
	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

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: MOMS AND DADS	FACILITY NUMBER: 306004379
	VISIT DATE: 01/31/2025

NARRATIVE

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In the garage, are two filing cabinets. One cabinet storing resident and staff records. Walkways were free of obstruction. There were three (3) additional refrigerators: two (2) for staff items and one (1) for residents. LPA Bentley also observed a washer and dryer in working condition, several boxes of diapers, and emergency bags for the residents prepared and ready to go.

The backyard was clean and free of clutter and debris. The side exit gates were clear and accessible and a shaded patio area with tables and seating observed. There was also a storage shed in the back yard, and additional storage for supplies. There are no bodies of water.

A review of four (4) residents (R1-R4) service files and five (5) staff (S1-S5) personnel files revealed to be complete. Two (2) residents and two (2) staff interviews were conducted. A review of the Medication Records Administration (MAR) and medication was conducted, and records were found to be in compliance.

The facility has liability insurance effective August 5, 2024 through August 5, 2025. A first aid kit was observed with all the required elements present. There is one (1) fully charged fire extinguisher, observed mounted in the kitchen with a last service date of May 22, 2024. Smoke and carbon monoxides detectors were tested and operational.

The last fire and disaster drill was conducted on September 21, 2024, for which a Technical Violation was issued. The facility does not current have a technical device with internet access available for resident only use, and a Technical Violation was given during today's visit. Hot water temperatures in bathrooms were measured and observed at 140.1 degrees Fahrenheit, for which a Type A Violation was given.

One (1) deficiency and two (2) Technical Violations were cited during today’s inspection visit.

An exit interview conducted and a copy of the report was provided to Administrator Reca Edora Yap.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -705-6014
LICENSING EVALUATOR NAME: Eboni Bentley	TELEPHONE: 714-552-7883
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/31/2025 06:25 PM - It Cannot Be Edited

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: MOMS AND DADS	FACILITY NUMBER: 306004379
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on ovservation and interview, the Licensee did not comply with the section cited above in two out of two bathrooms, which poses an immediate health, safety or personal rights risk to persons in care. LPA observed Bathroom #1 was measured at 140.6 F and Bathroom #2 measured at 140.6 degrees F.
	POC Due Date: 02/01/2025
	Plan of Correction
1 2 3 4	Administrator will obtain the correct temperature gauge and maintain a temperature log testing temperatures every two hours from 6pm on January 31, 2025 to 6pm on February 1, 2025. Administrator stated they will submit water temperature logs and pictures to CCLD via email to eboni.bentley@dss.ca.gov by POC due date February 1, 2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Lourdes Montoya	TELEPHONE: (714) -705-6014
Eboni Bentley	TELEPHONE: 714-552-7883
	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

LIC809 (FAS) - (06/04)

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