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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005172
Report Date: 01/30/2023
Date Signed: 01/30/2023 10:17:40 AM

Document Has Been Signed on 01/30/2023 10:17 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:PATCH'S FAMILY HOME LLCFACILITY NUMBER:
306005172
ADMINISTRATOR:MCCUNE, CRYSTALFACILITY TYPE:
735
ADDRESS:243 PAGEANTRY DRIVETELEPHONE:
(714) 528-5913
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 5DATE:
01/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Carrie Wicke, House ManagerTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by Carrie Wicke, House Manager and LPA explained the nature of the visit.

LPA Martinez accompanied by house manager began the tour of the inside and outside of the facility. There are five clients in care and there is no active covid-19 case in the facility. LPA was informed all clients were out in the community. There is a sign-in procedure in place and hand sanitizer for use. LPA observed required department postings, covid-19 precautionary postings in the facility as well as hand washing signs throughout the facility. The facility has an approved Mitigation Plan on file with CCLD. Facility has required Emergency Disaster Plan posted. All bathrooms observed to have a supply of soap, toilet paper and paper towels. LPA toured the client’s bedroom, all bedrooms observed to have all required components. The facility is equipped with sufficient hand hygiene supplies, cleaning and disinfecting provisions. Facility has an emergency food and water supply. Personal protective equipment (PPE) supply is available. Facility has a secure location for client’s medication, and it was observed there was a 30 day supply of medication for clients. LPA toured the outside of the facility and a observed a gated pool and shaded seating areas for client’s use.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the facility representative and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2023
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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