306004499-10-26-2022-22-AS-JHAY-CKKV9V-20221026161459

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004499
Report Date: 10/26/2022
Date Signed: 10/26/2022 04:15:09 PM

Document Has Been Signed on 10/26/2022 04:15 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:	DEL SOL HOME (BUENA PARK)		FACILITY NUMBER:	306004499
ADMINISTRATOR:	ANNAMARIE G. TOMILLOSO		FACILITY TYPE:	735
ADDRESS:	6652 NAOMI AVENUE		TELEPHONE:	(714) 752-6325
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 6		CENSUS: 4	DATE:	10/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Annamarie Tomill		TIME COMPLETED:	04:22 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

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by facility Administrator (AD) Annamarie Tomill. LPA Haley explained the reason for the visit, and was temperature checked upon entering the facility. AD Tomill has a current Administrators certificate that expires 04/02/23.

At 2:30 PM LPA Haley and AD Tomill began the inspection at the entrance of the facility. There was four clients present during the visit. A screening station with a thermometer, surgical mask, and hand sanitizer was observed right next to the main entrance.

Clients bedrooms were clean, organized, and had all necessary requirements: night stand, chair, lamp and storage space. Client bathrooms were clean and organized. Hot water temperature was measured at 108.8 degrees Fahrenheit in bathroom #1 and 107.9 degrees Fahrenheit in bathroom #2. In the hallway near client bedrooms and bathroom #2, LPA observed a locked hallway cabinet with cleaning supplies on one side and clean sheets on the other side of the cabinet. Below the cabinet, boxes of files were observed.

All required posting were observed on the walls in the living room and outside the main entrance. A file cabinet with client and staff files was observed next to bathroom #1. In the living room near the kitchen LPA observed a locked medication cabinet. Inside the medication cabinet were three first aid kits with all the required items. Across from the medication cabinet was a shelf with several files, folders, a cubby with staff items, and printer.

In the kitchen, all knives and sharp objects were locked in a drawer next to the stove. All hazardous cleaning chemicals were locked under the sink. A 2 day supply of perishable food items and a 7 day supply of non-perishable food items was observed. LPA observed a fully charged fire extinguisher on the floor where the kitchen borders the living room/dining room. Three of four burners on the stove were operational. LPA advised AD Tomill of the importance of the facility being in good repair at all times.

Continued on LIC809C Dated 10/26/22

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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 4

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: DEL SOL HOME (BUENA PARK)	FACILITY NUMBER: 306004499
	VISIT DATE: 10/26/2022

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
26
27
28
29
30
31
32

The backyard was large with lots of grass, a basketball hoop, and several benches. The side exit gate was self closing and self latching. On the opposite side of the facility, where the backyard and driveway meet, there's a shaded area with tables and chairs for clients to enjoy. LPA observed two locked storage sheds near the rear of the backyard. The smaller shed was used to store holiday decorations. The larger shed is used for storage of additional facility items: bedframes, mattresses and other miscellaneous items. Behind the storage sheds along the backyard fence line, LPA observed clutter and debris. The clutter consist of an old fence, some metal pole like items, a metal ladder, and old doors. Furthermore, a storage chest was observed with additional items that are no longer being used and need to be disposed of. LPA advised AD Tomill on the importance of keeping the facility clean and free of clutter and debris at all times.

The garage remains locked at all times, and was well stocked with additional supplies. LPA observed a box of emergency PPE supplies: mask, gowns, gloves, sanitizer, and disinfectants. Furthermore, a supply of emergency food and water was observed. There was an additional refrigerator with a supply of perishable food items. There is a cabinet with cleaning supplies, hand sanitizer, and other items. Next to the refrigerator, LPA observed a shelf with additional files. A couch and a TV was observed in the garage.

During the inspection, no bodies of water was observed. The smoke detectors tested operational.

Deficiencies are being cited during todays visit, and a Technical Advisory will be issued.

An exit interview was conducted and a copy of this report, LIC809D, LIC9102 (Technical Violation), and appeal rights were provided to Administrator Tomill.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 10/26/2022 04:15 PM - It Cannot Be Edited

Created By: Jerome Haley On 10/26/2022 at 03:46 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: DEL SOL HOME (BUENA PARK)	FACILITY NUMBER: 306004499
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80076(a)(21)

Food Services (a) In facilities providing meals to clients the following shall apply: (21) Equipment necessary for the storage, preparation, and service of food shall be provided and shall be well-maintained. This requirement is not met as evidenced by: While inspecting the ktichen arwea with Administrator Tomill, LPA observed the top left burner on the stove would not light without assistance.
	Deficient Practice Statement
1 2 3 4	Based on observation and acknowledgement from Administrator Tomill, the licensee did not comply with the section cited above which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/04/2022
	Plan of Correction
1 2 3 4	Administrator Annamarie Tomill agrees to have the stove replaced or repaired and provide proof to LPA Haley by the close of business Friday, November 4, 2022.

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.

SUPERVISOR'S NAME:

Luz Adams

LICENSING EVALUATOR NAME:

Jerome Haley

LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4