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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005205
Report Date: 08/24/2023
Date Signed: 08/24/2023 03:15:48 PM

Document Has Been Signed on 08/24/2023 03:15 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:NOUMEA CARE HOME IIFACILITY NUMBER:
306005205
ADMINISTRATOR:CONSOLACION BURGOSFACILITY TYPE:
735
ADDRESS:5978 NOUMEA STREETTELEPHONE:
(714) 686-1289
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY: 6CENSUS: 5DATE:
08/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Consolacion S BurgosTIME COMPLETED:
03:30 PM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Consolacion S Burgos and discussed the purpose of the inspection.
LPA reviewed Infection Control requirements. At about 12:30PM, LPA and AD 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 4-bedroom, 2-bathroom, one-story house with an attached garage that is being used for storage. There is a back yard with a patio cover for the clients. LPA observed 3 staff and 5 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: LPA inspected the 1 staff bedroom. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 111.7 degrees F in the hallway bathroom and 111.7 in the bedroom bathroom. Linens & Hygiene Supplies: linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA 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, including the wired smoke detectors/carbon monoxide detectors. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen drawer. Toxins: observed locked under the kitchen sink and in the garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. LPA discussed the facility’s licensing fees with AD. At about 1:00PM, LPA reviewed 5 client files and 4 staff files, interviewed 5 clients and 3 staff, inspected medications for 5 clients, and inspected client money and ledgers for 5 clients.
During the inspection, LPA and AD observed the following: based on training records, the administrator did not complete HIV/TB Training within the last 2 years.
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: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
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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Document Has Been Signed on 08/24/2023 03:15 PM - It Cannot Be Edited


Created By: Sean Haddad On 08/24/2023 at 02:33 PM
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: NOUMEA CARE HOME II
FACILITY NUMBER: 306005205

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documents, the administrator has not completed HIV/TB training within the last 2 years, which poses a potential health and safety risk to persons in care.
POC Due Date: 08/31/2023
Plan of Correction
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Licensee stated that they will have the administrator will complete HIV/TB Training immediately and submit proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023


LIC809 (FAS) - (06/04)
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