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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005172
Report Date: 01/29/2025
Date Signed: 01/29/2025 02:28:28 PM

Document Has Been Signed on 01/29/2025 02:28 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:PATCH'S FAMILY HOME LLCFACILITY NUMBER:
306005172
ADMINISTRATOR/
DIRECTOR:		MCCUNE, CRYSTALFACILITY TYPE:
735
ADDRESS:243 PAGEANTRY DRIVETELEPHONE:
(714) 528-5913
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 5DATE:
01/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:House Manager, Carrie WickeTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by House Manager Carrie Wicke and the purpose of the inspection was discussed.

During the inspection, LPA and HM conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, living room and observed the following:

This is a two-story home with three client bedrooms, two staff bedrooms, and four bathrooms. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. The backyard has a shaded sitting area and in-ground pool. Pool was observed to be fenced by a bar fence. Fence was observed to be at least five feet in height with a self-closing latch, located within six inches from the top of the gate. LPA did not observe any clients present, as they were away at day program. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 114.2 degrees Fahrenheit. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with service tag dated February 14, 2024. Gas stove, microwave, washer, and dryer were observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to clients. Medication was observed to be centrally stored in a locked cabinet. LPA reviewed medication and medication administration records for three of five clients and did not observe any discrepancies. LPA reviewed three client files and two staff files.

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 was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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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