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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004489
Report Date: 11/04/2022
Date Signed: 11/04/2022 10:34:42 AM

Document Has Been Signed on 11/04/2022 10:34 AM - 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:WENDY & PETER CARE HOMEFACILITY NUMBER:
306004489
ADMINISTRATOR:LINDA PHUONG LINH TRANFACILITY TYPE:
735
ADDRESS:273 23RD STREETTELEPHONE:
(949) 645-8697
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 6CENSUS: 6DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Phil TranTIME COMPLETED:
10:45 AM
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On 11/04/2022, Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit to Wendy & Peter Care Home for the purpose of conducting a Required 1 Year emphasizing on the Infection Conrol. LPA was greeted and granted entry by Care Staff (CS) Arnel Magkawas and completed the Coronavirus 2019 (COVID-19) screening procedure. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents visitor's temperatures on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility.

The facility is a single level structure and licensed for six ambulatory clients. This facility offers a Level 2 service. As of today, there are six clients living in the facility. One client was present learning virtually.

At 9:45am, LPA Cho conducted a tour of the physical plant along with Care Staff Arnel Magkawas. The home consists of three client bedrooms with two client bathrooms. There is a private staff bedroom. The client bedrooms were checked. Client bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets, water faucets worked properly and showers were free of mold/mildew. Client bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in all bathrooms. LPA Cho tested the hot water temperature in the client bathrooms and the temperatures measured at 105.2 degrees Fahrenheit in Bathroom #1 and 109.9 degrees Fahrenheit in Bathroom #2. LPA Cho inspected the kitchen. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was mounted, fully charged, and purchased on 11/04/2022. The smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the clients.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: WENDY & PETER CARE HOME
FACILITY NUMBER: 306004489
VISIT DATE: 11/04/2022
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LPA Cho toured the outside grounds. There was no body of water present. There was shading and sufficient seating for clients. Walkways around the home were clear of hazards, and the exit gate was self-closing and self-latching. There were no security bars or weapons on the premises. Facility has sufficient emergency food/water and PPE supplies.

At 10:21am, Administrator Phil Tran arrived at the facility to participate in the exit interview. Admin was reminded of the upcoming annual licensing fee due on or before November 29, 2022. LPA provided the pin number to ensure payment is received on time.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Administrator Phil Tran, and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC809 (FAS) - (06/04)
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