<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004499
Report Date: 11/08/2023
Date Signed: 11/08/2023 11:40:18 AM

Document Has Been Signed on 11/08/2023 11:40 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:DEL SOL HOME (BUENA PARK)FACILITY NUMBER:
306004499
ADMINISTRATOR:ANNAMARIE G. TOMILLOSOFACILITY TYPE:
735
ADDRESS:6652 NAOMI AVENUETELEPHONE:
(714) 752-6325
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 6DATE:
11/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Annamarie TomillosoTIME COMPLETED:
11:55 AM
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) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Administrator (AD) Annamarie Tomilloso and the purpose of the inspection was discussed.

During the inspection LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a one-story home with seven bedrooms, two bathrooms, and attached two-car garage. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. The backyard and courtyard have multiple sitting areas, however, are not shaded; a Technical Advisory was given on this date. Discarded items were also observed in the backyard and courtyard; a Deficiency was cited on this date. LPA observed three clients present, as all other clients were away at day program. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 115.5 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Appliances were all inspected. Sharps were observed locked in a kitchen drawer. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication cabinet was observed to be locked. LPA reviewed six client files and three staff files. LPA interviewed staff and clients present.

Based on the observations made during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2023
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 3
Document Has Been Signed on 11/08/2023 11:40 AM - It Cannot Be Edited


Created By: Claudia Gutierrez On 11/08/2023 at 10:44 AM
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: 11/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as empty carton boxes, furniture sitting on its side, dusty printer, patio table with missing glass, and sundried umbrella were observed to be discarded in the backyard which poses a potential safety and personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
1
2
3
4
AD stated they would dispose of all items and maintain courtyard and backyard free of hazards and all discarded items. AD will provide LPA with picture proof of correction via email by POC date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3