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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005174
Report Date: 09/20/2022
Date Signed: 09/20/2022 10:59:52 AM


Document Has Been Signed on 09/20/2022 10:59 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:SAN CLEMENTE CARE HOMEFACILITY NUMBER:
306005174
ADMINISTRATOR:CASTEN, LUISITOFACILITY TYPE:
740
ADDRESS:2927 BONANZATELEPHONE:
(310) 975-5634
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:6CENSUS: 6DATE:
09/20/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Anjelica Valle and mercy AngTIME COMPLETED:
11:18 AM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 09/09/2022. LPAs were greeted and granted entry into the facility by Caregiver Anjelica Valle and explained the reason for the visit. Administrator Mercy Ang arrived during the visit. LPAs toured the facility with Caregiver Anjelica Valle at 10:48 AM to ensure violations have been corrected.

*Deficiency cited under Title 22 Regulation 87465(h)(2) pertaining to Centrally Stored Medications has been cleared. During today's visit, medications are secured. Licensee has complied with the terms of the POC.



Licensee has been advised to maintain all items especially those that were previously deficient in the facility in accordance with Title 22 Regulations.





Copy of this report was provided to the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
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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