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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004719
Report Date: 12/13/2021
Date Signed: 12/15/2021 09:31:08 AM

Document Has Been Signed on 12/15/2021 09:31 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:ST. SIMON HOME IIFACILITY NUMBER:
306004719
ADMINISTRATOR:RON MARCHELLOFACILITY TYPE:
740
ADDRESS:4704 AVENIDA DE LAS FLORESTELEPHONE:
(951) 545-2934
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 6CENSUS: 5DATE:
12/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ryan & Sheryll HernandezTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPA), Kathrina Chin and Kevin Saborit-Guasch conducted an unannounced visit for the purpose of conducting a required annual visit. LPAs were greeted by Ryan and Sheryll Hernandez, Caregivers and greeted into the facility after completing the required COVID-19 screening procedure.

LPAs toured the facility. There are five residents residing in the facility and no active COVID-19 cases. All residents appeared clean and well taken care of. LPAs observed required postings in the facility as well as hand washing signs in the restrooms. All restrooms observed had ample soap/sanitizer and appeared clean, with adequate signage. Resident bedrooms appeared clean and sanitary and had all required components. LPAs observed the emergency disaster and evacuation plans. Facility has back-up emergency food and water supply as well as PPE supplies. LPAs reviewed the COVID-19 mitigation plan of the facility.

Smoke detectors, carbon monoxide and auditory exit alarms were tested and were operational. Bathrooms were observed to be in good repair; and provided with grab bars and non-skid floor mats. Hot water was measured at 116.4 degrees Fahrenheit. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguishers were mounted and charged. For the exterior portion, facility had patio furniture in good repair and grounds were free of tripping hazards.


No deficiencies cited this review as per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kathrina Chin
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2021
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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