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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005189
Report Date: 03/10/2022
Date Signed: 03/10/2022 10:58:42 AM

Document Has Been Signed on 03/10/2022 10:58 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:EJ HOMESFACILITY NUMBER:
306005189
ADMINISTRATOR:CRUZ, PLACIDA DELAFACILITY TYPE:
735
ADDRESS:1231 WEST ARLINGTON AVETELEPHONE:
(714) 244-0656
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 1DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Placida CruzTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted and granted entry by staff. LPA explained the reason for the visit. LPA and staff toured the facility. Facility is a single story home with 5 bedrooms, 1 bedroom is for staff, 3 bathrooms, living room, dining room, kitchen and a 2 car garage. LPA observed all client bedrooms had the required furnishings. Hot water temperature measured between 114.0 degrees Fahrenheit and 114.6 degrees Fahrenheit. All bathrooms were clean and operational. Smoke detectors/carbon monoxide detectors tested operational. LPA observed a 2 day perishable food supply and a 7 day non-perishable food supply on hand. LPA observed the cleaning supplies were kept locked under the kitchen sink. LPA observed knives are kept locked in a kitchen drawer. The stove lights unassisted. The kitchen is clean and organized. LPA observed the fireplace in the living is screened. LPA observed medications are kept locked in a cabinet. The dining room has a large table and 6 chairs. There is a TV in the dining room for clients. The dining room also has a desk and chair for staff. LPA and staff toured the backyard. The shed in the backyard is used for storage and kept locked. There is a covered patio with a seating area for clients. No bodies of water observed. Both exit gates on each side of the house are operational. No obstacles or hazards observed in the backyard. LPA inspected the First Aid kit. The First Aid Kit had all the required elements. The garage is used for laundry and storage and dangerous items such as cleaning supplies and laundry supplies are kept locked in a cabinet. Administrator Placida Cruz arrived after LPA and staff completed the tour. Her Administrator's Certificate expires on 8/23/22. Facility has a mitigation plan that is pending approval. No deficiencies observed during this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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