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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004609
Report Date: 10/12/2021
Date Signed: 10/12/2021 01:55:27 PM

Document Has Been Signed on 10/12/2021 01:55 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:SOMERSET HOME 3FACILITY NUMBER:
306004609
ADMINISTRATOR:LENETTE L. BELENFACILITY TYPE:
735
ADDRESS:1735 W. FERN DRIVETELEPHONE:
(714) 814-8149
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 6CENSUS: 6DATE:
10/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marvelita OntiverosTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Norman Woodridge conducted a Covid-19 Annual Inspection at the facility. Upon arrival, LPA informed lead caregiver, Marvelita Ontiveros (S1), of the purpose of the visit and was granted entry into the building. LPA and S1 conducted a tour of the inside and outside of the facility, common areas, resident rooms, garage, and kitchen.

LPA discussed and observed the following:

There were 6 residents present at the facility doing activities. Resident rooms were clean and organized. LPA observed a 2-day supply of perishables and a 7-day supply of nonperishables. LPA observed hallways and walkways that were free of obstruction. LPA observed PPE stockpile for staff and PPE for residents. LPA reviewed policies and Covid-19 sign in sheets used to document temperature checks. LPA provided technical assistance regarding Covid-19 isolation procedures. LPA discussed signage and Provider Information Notice 21-38-ASC: Update Guidance for the Use of Masks, Surgical Masks, Respirators Related to Coronavirus Disease 2019 (COVID-19).

No deficiencies were noted during the inspection.



An exit interview was conducted with S1 and a copy of this report was provided.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Norman Woodridge
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2021
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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