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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005229
Report Date: 04/27/2023
Date Signed: 04/27/2023 02:46:18 PM

Document Has Been Signed on 04/27/2023 02:46 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:EL CINCO FAMILY HOME CAREFACILITY NUMBER:
306005229
ADMINISTRATOR:CINCO, EMMYLOUFACILITY TYPE:
735
ADDRESS:24892 STEM AVETELEPHONE:
(949) 716-9467
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 5DATE:
04/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Emmylou CincoTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Administrator (AD) Emmylou Cinco and the purpose of the inspection was discussed.

During the inspection LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, staff room, kitchen, garage and observed the following:

This is a two-story house; the first floor consists of two client bedrooms, two bathrooms, and one staff bedroom. The second story consists of two bedrooms and one bathroom and is used as staff quarters and storage. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. The back yard has a shaded sitting area. LPA did not observe any clients present. Per AD, all clients were away at day program. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 107.6 F degrees. LPA observed emergency disaster plan and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. LPA reviewed facility fire drill log that indicated the last fire drill was conducted on 1/09/23. Gas four burner stove, dishwasher, microwave, washer, and dryer were all inspected. Sharps were observed locked in the kitchen drawer. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication was observed to be locked. LPA reviewed four out of four client files and AD’s personnel file. Clients were not present to be interviewed.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
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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