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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005150
Report Date: 07/14/2022
Date Signed: 07/14/2022 02:01:35 PM

Document Has Been Signed on 07/14/2022 02:01 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:NOUMEA CARE HOMEFACILITY NUMBER:
306005150
ADMINISTRATOR:CONSOLACION BURGOSFACILITY TYPE:
735
ADDRESS:729 S WASCO RDTELEPHONE:
(714) 891-1233
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 2DATE:
07/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Fortune Saturno & Mimilanely SaturnoTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. LPA Haley was screened and temperature checked upon entering the facility. Administrator (AD) Consolacion Saturno has a current administrators certificate that expires 1/18/23.

At 11:30 AM LPA Haley began the tour of the facility with staff. There were two clients present for the visit. All client bedrooms were clean, well organized, and had all necessary elements. Both client bathrooms were clean and organized. Hot water temperature was measured at 114.8 degrees Fahrenheit in client bathroom #1 and 108.6 degrees Fahrenheit in client bathroom #2.

All required postings are posted in the living room near the entrance of the home. Right next to the front door there's a closet with extra hygiene supplies for the clients. There's a screening station set up in the living room with temperature log's, hand sanitizer, wipes and face mask. In the living room there's a locked cabinet with staff and client files. On top of the cabinet there's an emergency supply of PPE. LPA Haley also observed emergency kits for the clients.

The backyard was clean, organized and free of tripping hazards. LPA Haley observed a side exit gate that was self closing and self latching. There was a shaded patio area with tables, chairs and fitness equipment.

The garage was clean and well organized. In the garage LPA Haley observed an emergency supply of food and water. There were locked cabinets in the garage that are use by staff. There was a locked space in the garage used for the washing machine, and hazardous chemicals.


Continued on LIC 809 C
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 306005150
VISIT DATE: 07/14/2022
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The kitchen was clean and well organized. Hazardous cleaning materials were locked under the sink and knives and sharp objects were locked under the stove. LPA Haley observed a two day supply of perishable items, a 7 day supply of non perishable items and a supply of fresh fruits. There was a locked medication cabinet in the kitchen and a first aid kit with all the required elements in the locked medication cabinet. LPA Haley observed a mounted and fully charged fire extinguisher on the wall near the medication cabinet.

Kitchen #2 was clean and well organized. Staff stated that sometimes the clients like to eat in the second kitchen. There were no knives, sharp objects or cleaning materials in kitchen #2. LPA Haley observed a refrigerator with a plenty of fresh food items. The cabinets were mainly used for storing random items; however, there were a few canned food items present in the cabinets. A mounted and fully charged fire extinguisher was observed on the wall near the kitchen table.

No bodies of water were observed. All smoke detectors were tested and are operational. No deficiencies are being cited during todays visit. An exit interview conducted and a copy of this report was left at the facility with the staff.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC809 (FAS) - (06/04)
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