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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005189
Report Date: 03/15/2024
Date Signed: 03/15/2024 02:57:18 PM

Document Has Been Signed on 03/15/2024 02:57 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: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: 4DATE:
03/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:49 PM
MET WITH:Emmanuel Villacorta, Licensee and Jane Villacorta, AdministratorTIME COMPLETED:
03:15 PM
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On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required Annual inspection. LPA was greeted and granted entry into the facility by Administrator (AD) Jane Villacorta. Licensee (L) Emmanuel Villacorta arrived during today's visit.
This is a level 3 home Adult Residential Facility for Developmentally Disabled Adults age range 18 through 59 years of age and approved for five (5) Ambulatory clients, (1) one Non Ambulatory client. There are four (4) clients in care at this time. There are no active COVID-19 cases in the facility at this time. Administrator Jane Villacorta has a Pending renewal Administrator Certificate with expiration date of January 31, 2024. (AD) Villacorta indicated submitting renewal documentation on 1/29/2024, status-pending online.
LPA Quiroz along with (AD) Villacorta toured the interior and exterior of the facility. During today's inspection tour, LPA Quiroz observed Client 1 (C1) in their bedroom resting. Client 2 (C2) and Client 3 (C3) arrived on or about 2:15pm. Client 4 (C4) arrived on or about 2:30pm from Day Program. LPA Quiroz interacted and interviewed with Licensee, (AD) Jane Villacorte and 4 of 4 clients during today's visit.
On today's date, while conducting inspection tour of kitchen area, LPA Quiroz observed 2 of 4 burners not lighting up. Licensee indicated "After cleaning they don't work sometime, but we're going to get a new one."
(See LIC 9102-TV )
LPA Quiroz inspected client's bedrooms and bathrooms. The water temperature in client's bathroom was recorded to be 105.8 degrees Fahrenheit. LPA Quiroz inspected client’s bedrooms and appeared to be clean. Facility temperature in client's bedrooms and throughout the facility was recorded to be within normal limits. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in the garage area readily available for staff and clients in care. Fire extinguisher observed last serviced on 1/11/2024. Two sets of functional and operational washer and dryer in the garage area. LPA Quiroz toured the outside of the facility and observed seating and shaded area in the backyard for residents and visitor's enjoyment. CONTINUED LIC 809-C...
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: EJ HOMES
FACILITY NUMBER: 306005189
VISIT DATE: 03/15/2024
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CONTINUED...LPA Quiroz reviewed 4 of 4 client's file and Personal & Incidental (P&I) ledgers during today's visit.
During today's visit, LPA Quiroz provided Consultation on Title 22 and Infection control. An exit interview was conducted with Licensee, (AD) Jane Villacorte and a copy of this report, LIC 858, LIC 811- Confidential names, were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC809 (FAS) - (06/04)
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