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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004663
Report Date: 01/18/2024
Date Signed: 01/18/2024 03:19:51 PM

Document Has Been Signed on 01/18/2024 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:PUNZALAN HOMESFACILITY NUMBER:
306004663
ADMINISTRATOR:EDGARDO PUNZALANFACILITY TYPE:
735
ADDRESS:719 ROANNE STREET, N.TELEPHONE:
(714) 220-2528
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 5DATE:
01/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Nikki Jay - AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by DSP Carlos Tiquia. AD Nikki Jay joined the inspection during the facility tour.

The facility is a one-story home with six client bedrooms, two bathrooms, kitchen, dining room, living room, backyard and attached 2-car garage. The garage is used as an office space and storage area for the staff. LPA observed emergency supplies and water in the garage. LPA noted one client was away at day program and one was away at a doctor appointment. LPA noted the clients present were non-verbal. Facility appears clean and sanitary. All residents rooms had required elements, including bed, chair, closet space and ample lighting. Facility had extra linens for clients in the hallway closet and the garage. Restrooms are stocked with soap. Paper towels are brought in as needed due to multiple clients engaging in behavior that involves clogging the toilet with paper towels. Hot water measured at 112.4 degrees Fahrenheit and 109.9 degrees Fahrenheit in the two bathrooms. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in drawers in the kitchen. Chemicals are stored separately from items used for food preparation. Medication for each resident is kept locked in cabinets in the dining room. The backyard has a shaded seating area. The two exit gates are unlocked and latch. LPA observed exit gates to be unobstructed. LPA reviewed three of the five client files, four personnel files and the P&I for all five residents. Facility has board games, exercise equipment, electronics, music and more for client use. Emergency contacts, Menu and Calendar are posted and available for review.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was provided to the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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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