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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004460
Report Date: 02/08/2023
Date Signed: 02/08/2023 02:41:10 PM

Document Has Been Signed on 02/08/2023 02:41 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:REAL HEARTS HOMEFACILITY NUMBER:
306004460
ADMINISTRATOR:EVELYN SCHAEFERFACILITY TYPE:
735
ADDRESS:2860 W.COOLIDGE AVENUETELEPHONE:
(714) 886-2076
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: DATE:
02/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Charlie CaolengTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by care staff. LPA met with Charlie Caoleng, care staff and explained the nature of the visit.

LPA Martinez accompanied by care staff began the tour of the inside and outside of the facility. There are six clients in care and there are no active covid cases in the facility. Upon entry LPA observed clients in the living room. There is a sign-in procedure in place at the front door of the facility prior to entering. LPA observed required department postings, and covid precautionary postings throughout the facility. The facility has a Mitigation Plan on file with CCLD. Facility has required Emergency Disaster Plan posted. LPA inspected the kitchen and observed there is a minimum of seven day of non-perishable foods and two day of perishable foods available. Facility has an emergency food and water supply. Facility bathroom observed to have a supply of soap and appeared clean. LPA toured client’s bedrooms, all bedrooms observed to have all required components. Clients were observed in their bedrooms. The facility is equipped with hygiene, cleaning and disinfecting supplies. Facility has a secure location for client’s medication, and it was observed there was a 30 day supply of medication for clients. LPA observed a supply of personal protective equipment (PPE) supply stored with medication storage. LPA toured the outside of the facility and observed shaded seating are for clients use.

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: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2023
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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