306004682-5-25-2023-22-AS-CGUZ-CS6VFR-20230525162422

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004682
Report Date: 05/25/2023
Date Signed: 05/25/2023 04:24:28 PM

Document Has Been Signed on 05/25/2023 04:24 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:	CARRA HOMES, INC.		FACILITY NUMBER:	306004682
ADMINISTRATOR:	CAROLYN JIMENEZ		FACILITY TYPE:	735
ADDRESS:	8074 CACTUS CIRCLE		TELEPHONE:	(714) 742-3548
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 6		CENSUS: 6	DATE:	05/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Carolyn Jimenez		TIME COMPLETED:	04:40 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Dwayne Mason Jr and Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPAs were greeted and granted entry into the facility by Administrator (AD) Carolyn Jimenez and discussed the purpose of the inspection. During the inspection LPAs and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, staff room, office, kitchen, garage and observed the following:

This is a one-story house with three client bedrooms, two bathrooms, one office and one staff bedroom. All client bedrooms had the required furnishings. LPAs observed all client beds had linens and blankets. LPAs observed all windows were screened. The back yard has three shaded sitting areas. LPAs observed three staff and three clients present. Per AD, three 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 119.4 F degrees. An emergency supply of water and juice were observed being stored in one of the bathrooms; a Technical Advisory was given on today’s date.

LPAs observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted in facility. Food menu was also posted and visible. LPAs 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. Kitchen refrigerator and four out of four gas stove burners tested operable. Sharps were observed locked in the pantry. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents. Medication was observed to be locked. The first aid kit has all the required elements. LPAs reviewed five client files and five staff files. LPAs observed AD’s Certification is expired; a Deficiency was issued on this date. LPAs interviewed three clients and two staff.

Based on the observations made during today’s inspection, one deficiency and one technical advisory are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

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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Document Has Been Signed on 05/25/2023 04:24 PM - It Cannot Be Edited

Created By: Claudia Gutierrez On 05/25/2023 at 03:27 PM

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: CARRA HOMES, INC.	FACILITY NUMBER: 306004682
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85064(b)

Administrator Qualifications and Duties

(b) All adult residential facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as AD is not currently certified. AD certificate has been expired since December 2021, which poses a potential personal rights risk to persons in care.
	POC Due Date: 06/23/2023
	Plan of Correction
1 2 3 4	AD stated they would submit a Designation of Responsiblity to CCL to designate Assistant AD as AD as they have a current, unexpired certificate.

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: 05/25/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC809 (FAS) - (06/04)

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