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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004609
Report Date: 07/05/2022
Date Signed: 07/05/2022 10:19:45 AM

Document Has Been Signed on 07/05/2022 10:19 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: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:
07/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Marvelita Ontiveros- Caregiver, Alma Ecelan- Administrator, Lenette Belen- Licensee TIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA)Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Caregiver Marvelita Ontiveros and explained the reason for the visit. Administrator Alma Encelan and Licensee Lennette Belen arrived 9:30AM.

At 9:16 AM, LPA toured the facility with Caregiver Marvelita Ontiveros and later Administrator Alma Encelan joined. Facility is 4 bedroom, 2 bathroom, single story home with an attached garage. Facility has 5 clients present during today's visit. LPA observed clients relaxing in the facility. Facility appears clean and sanitary. All clients rooms had the required elements as well as restrooms stocked with soap. LPA observed supply of emergency food with packs of water. LPA observed locked medication cabinet. LPA toured the outside grounds and exit gates are unlocked and self latching. Facility has a plan for covid testing clients and staff as needed as well as a plan for isolation. All staff and clients are vaccinated for Covid-19. LPA reviewed all client's files and all contained required documentation including updated emergency information.


No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2022
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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