<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005172
Report Date: 02/12/2024
Date Signed: 02/12/2024 10:35:50 AM

Document Has Been Signed on 02/12/2024 10:35 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: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:
02/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Carrie WickeTIME COMPLETED:
10:50 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad and Kevin Saborit-Guasch for the purpose of conducting a Required – 1 Year Inspection. LPAs met with Staff #1 (S1) Carrie Wicke and discussed the purpose of the inspection. Administrator (AD) Crystal Mccune was not present during the inspection. LPAs reviewed Infection Control requirements. At about 8:45AM, LPAs and S1 conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure: facility is a 5-bedroom, 4-bathroom, two-story house with an attached garage that is being used for storage. There is a back yard with a patio cover for the clients. LPAs observed 1 staff and no clients present at the facility. Client Bedrooms: the 3 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms: LPAs inspected the 2 staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 116.9 degrees F in the common client bathroom. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen and laundry room. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 9:30AM, LPAs reviewed 5 client files and 3 staff files, interviewed 1 staff, inspected medications for 5 clients, and inspected client money and ledgers for 5 clients. During the inspection, LPAs and S1 observed the following: based on observation, the facility's fire extinguisher has not been inspected in over a year; based on observation, the facility has 2 stories but does not have an evacuation chair. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2024
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 3
Document Has Been Signed on 02/12/2024 10:35 AM - It Cannot Be Edited


Created By: Sean Haddad On 02/12/2024 at 10:12 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PATCH'S FAMILY HOME LLC
FACILITY NUMBER: 306005172

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the facility's fire extinguisher has not been inspected in over a year, which poses a potential safety risk to persons in care.
POC Due Date: 03/11/2024
Plan of Correction
1
2
3
4
 Licensee stated they will have the fire extinguisher serviced or replaced and will submit proof to LPA by POC due date.
Type B
Section Cited
HSC
1565(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell in a residential facility serving adults, on or before July 1, 2021.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the facility has 2 stories but does not have an evacuation chair, which poses a potential safety risk to persons in care.
POC Due Date: 03/11/2024
Plan of Correction
1
2
3
4
During the inspection, the licensee purchased an evacuation chair and LPA confirmed. POC CLEARED.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3