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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005150
Report Date: 10/30/2023
Date Signed: 10/30/2023 09:15:57 AM

Document Has Been Signed on 10/30/2023 09:15 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:
(714) 891-1233
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 5DATE:
10/30/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Fortune Saturno, Melba SantosTIME COMPLETED:
09:30 AM
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This unannounced POC inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of verifying correction of deficiencies issued during the Required – 1 Year Inspection conducted on 10/09/23. LPA met with Staff #1 (S1) Fortune Saturno and discussed the purpose of the inspection. Administrator (AD) Melba Santos arrived during the inspection. During the inspection, LPA and AD toured the facility, reviewed documents, and observed the following:

Type A Violation cited under California Code of Regulations (CCR) Title 22, Section 80010(b) pertaining to Fire Clearance has been CLEARED. On 10/19/23, a new fire clearance was approved by the Anaheim Fire Department for 5 ambulatory and 1 non-ambulatory in room #2 and the facility’s license was updated to reflect this new fire clearance. During today’s inspection, LPA reviewed the Physician’s Reports for all 5 clients, confirmed that the facility has only 1 non-ambulatory client, and confirmed that the non-ambulatory client is in room #2. The facility is now following its fire clearance.

Based on the observations made during today’s inspection, no deficiencies 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 and clear letters for citations cleared during this inspection were discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
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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