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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004609
Report Date: 09/29/2023
Date Signed: 09/29/2023 03:19:53 PM

Document Has Been Signed on 09/29/2023 03:19 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
ORANGE COUNTY ASC, 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:
09/29/2023
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
01:47 PM
MET WITH:Alma Encelan - AdministratorTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility to conduct an unannounced Required 1 Year Inspection. At 1:45 pm, LPA was greeted and granted entry by Lead Staff Marvelita Ontiveros. Administrator Alma Encelen arrived at the facility at approximately 2:00 pm. LPA observed residents present to be participating in a group movie night.

Structure: The facility is a one-story home with three shared resident bedrooms, one resident bathroom, TV room, kitchen, dining room, staff bedroom, one staff bathroom, recreational room, backyard and attached two car garage. That backyard has one exit gate on both sides. There is one shaded seating area in the backyard and one shaded seating area in the front yard.

Client Bedrooms: All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. Facility provides privacy curtains in shared rooms for additional resident privacy

Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked in the laundry room.

Medications, First-Aid Kit & Book: Medication will be stored in a locked cabinet in the hallway. First aid kit is stored with the medication. LPA reviewed 3 clients’ medication. Medication was observed to be properly organized, documented and administered.

Resident & Staff Files: Records are kept on a shelf in the living room. LPA reviewed the AD file, 2 staff files and 3 client files.

Fire Extinguisher: The fire extinguisher is fully charged.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SOMERSET HOME 3
FACILITY NUMBER: 306004609
VISIT DATE: 09/29/2023
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Activity Materials: The facility has coloring books, games, board games, puzzles, arts and craft supplies, exercise equipment and community activities.

Bathrooms: All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 118.2 degrees Fahrenheit in the bathroom in the hallway.

Linens & Hygiene Supplies: A supply of extra linens and hygiene supplies is stored in cabinets in the hallway.

Emergency Phone Numbers, Exit Plan & Menu: Posted and available for review

Food Service: There is a supply of 2-day perishable and 7-day of non-perishable food on hand. The emergency food supply is housed out of the way in the TV Room.

Smoke Detectors: Smoke and carbon monoxide detectors tested operational.

Appliances: Gas 4 burner stove with 1 oven, 2 refrigerators, 1 freezer chest, dish washer, microwave, washer, and dryer are operational.

Based on the observations made during today's visit, no deficiency is being cited as per Title 22 Division 6 Chapter 2 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided during this visit.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC809 (FAS) - (06/04)
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