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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004807
Report Date: 12/15/2022
Date Signed: 12/15/2022 11:07:01 AM

Document Has Been Signed on 12/15/2022 11:07 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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LINA'S BOARD AND CAREFACILITY NUMBER:
306004807
ADMINISTRATOR:CRYSTAL LARAFACILITY TYPE:
735
ADDRESS:1511 E. STAFFORD STREETTELEPHONE:
(714) 558-6007
CITY:SANTA ANASTATE: CAZIP CODE:
92701
CAPACITY: 6CENSUS: 3DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Administrator, Crystal LaraTIME COMPLETED:
11:25 AM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and was granted entry into the facility by staff. LPA explained the reason for the visit to Caregiver Gemma Geraldo. Administrator Crystal Lara arrived during visit.

During the visit LPA toured the facility with Administrator. Facility is a 5 bedroom (3 client rooms, 2 staff rooms) and 2 bathroom single story home. There are 3 Clients in care. During the visit 1 client was present and 2 other clients were at Day program. Client was observed relaxing in living room watching TV. LPA observed facility has required Department postings. LPA observed Emergency Disaster Plan and Personal Rights. LPA observed Administrator Certificate expiring on 02/25/24. LPA toured all clients rooms. Client rooms had proper bedding and storage space. All restrooms observed contained working wash basin, soap, toilet paper and towels. Bathrooms had proper hand washing signs posted. Facility has ample supply of hygienic supplies. Facility has night lights posted in hallways.

Facility has ample supply of PPE supplies. Facility has 2 refrigerators and pantry's with ample food supply. LPA observed facility has emergency food and water supply. Facility has 2 fire extinguishers mounted and fully charged. Facility has a secured location for Client medication and files. Facility has 30 days supply of medications for clients. LPA reviewed Clients files during visit. LPA observed 3 out of 3 client files. Clients emergency contact information and physicians reports are current. Facility has designated visitation areas.

An exit interview was conducted with Administrator and copy of report was left at facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2022
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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