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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005150
Report Date: 09/06/2024
Date Signed: 09/06/2024 11:03:05 AM

Document Has Been Signed on 09/06/2024 11:03 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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:NOUMEA CARE HOMEFACILITY NUMBER:
306005150
ADMINISTRATOR/
DIRECTOR:		CONSOLACION BURGOSFACILITY TYPE:
735
ADDRESS:729 S WASCO RDTELEPHONE:
(714) 891-1233
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 6DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Melba Santos, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 at 8:00am. During today’s visit, LPA met with Melba Santos, Assistant Administrator (AA).

The facility is a level two single story building with an approved fire clearance of six ambulatory of which rooms three or four may be non-ambulatory. The facility currently has a census of six clients in care.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two client bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 109.4 and 112.4 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on January 23, 2024. The facility’s last fire drill was conducted on July 14, 2024. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed.

LPA reviewed three of three staff training and fingerprint records and a complete review of client records. Admissions Agreements are from Regional Center of Orange County for Title 17 but need Title 22 Admissions Agreements. Client P&I records were reviewed and were accurate. LPA interviewed alert clients regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that Assistant Administrator has an administrator certificate pending renewal which will expire on June 30, 2026.

(See LIC 809-C)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: NOUMEA CARE HOME
FACILITY NUMBER: 306005150
VISIT DATE: 09/06/2024
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(Continued from LIC 809)

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Melba Santos, Assistant Administrator and a copy of the report, LIC 9102-TV and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
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