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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005150
Report Date: 04/20/2022
Date Signed: 04/20/2022 10:32:53 AM

Document Has Been Signed on 04/20/2022 10:32 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:NOUMEA CARE HOMEFACILITY NUMBER:
306005150
ADMINISTRATOR:CONSOLACION BURGOSFACILITY TYPE:
735
ADDRESS:729 S WASCO RDTELEPHONE:
7148911233
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 5DATE:
04/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator Melba Santos TIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility to conduct a case management for an incident. LPA met with Administrator (AD) Melba Santos and stated the purpose of this visit.

On April 19, 2022, Community Care Licensing Division (CCLD) Orange Office received a report stating that about 2:27 PM of April 18, 2022, the facility received a call from responsible party that Client 1 passed away in the hospital. Client 1 was admitted in the hospital since April 11, 2022.

For this visit, LPA toured the interior and exterior portions of the facility; and observed three clients and 2 staff members on the floor. Two clients were out attending respective day program. After the tour, LPA did interviews and file review.

For this visit, no deficiency was noted for areas observed. No citation was issued.

LPA Marin conducted an exit interview with AD Melba Santos. AD agreed to provide CCLD with copy of pertinent records and official death report once they become available. Copy of this report was left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2022
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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