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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005205
Report Date: 08/16/2024
Date Signed: 08/16/2024 11:10:04 AM

Document Has Been Signed on 08/16/2024 11:10 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:NOUMEA CARE HOME IIFACILITY NUMBER:
306005205
ADMINISTRATOR/
DIRECTOR:		CONSOLACION BURGOSFACILITY TYPE:
735
ADDRESS:5978 NOUMEA STREETTELEPHONE:
(714) 686-1289
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY: 6CENSUS: 6DATE:
08/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:10 AM
MET WITH:Consolacion BurgosTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by Administrator (AD) Consolacion Burgos. The facility is licensed for 6 ambulatory clients. Currently there are 6 clients living here during today's visit.

At 8:32 AM, LPA Tea reviewed six client files and two staff files. Client files and staff files contained all required documentation except one minor issue, there are no client admission agreements that meets Title 22. Client records contain Orange County Regional Center admission agreements. LPA advised AD to draft admission agreements based on Title 22. The administrator certificate expires on January 18, 2025.



LPA Tea along with staff Melba Santos toured the facility at 9:42 AM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a one-story home with three client bedrooms, one staff room, and two bathrooms. The facility has a kitchen, dining room, family room and living room with an attached garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured at 114.9 F degrees. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. LPA also observed toxin substances to be secured and locked and inaccessible to clients underneath the sink and in a storage closet in the garage.

Continuation of annual report on LIC809C

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: NOUMEA CARE HOME II
FACILITY NUMBER: 306005205
VISIT DATE: 08/16/2024
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The fire extinguisher in the kitchen is fully charged and last inspected April 20, 2024. The facility’s last fire drill was conducted on August 12, 2024. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade. LPA observed emergency supplies, food, and water in the garage. LPA Tea observed clients leaving for their day programs. The staff provide activities based on client’s personal preference such as puzzles and art coloring. Occasionally they would go out for walks, and staff take them to outings like the beach and bowling.

At 9:43 AM LPA reviewed medication storage and administration. Medications are stored in a locked cabinet in the garage. Medications are being administered per physician order. P&I Funds were checked and meet department standards. LPA interviewed clients regarding their quality of care and spoke to staff present regarding care provided.



Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with AD Consolacion Burgos and a copy of this report LIC809, 809-C, LIC858, LIC859, and LIC9102TV was read and provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC809 (FAS) - (06/04)
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