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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005229
Report Date: 12/11/2024
Date Signed: 12/11/2024 11:34:10 AM

Document Has Been Signed on 12/11/2024 11:34 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:EL CINCO FAMILY HOME CAREFACILITY NUMBER:
306005229
ADMINISTRATOR/
DIRECTOR:		CINCO, EMMYLOUFACILITY TYPE:
735
ADDRESS:24892 STEM AVETELEPHONE:
(949) 716-9467
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 4DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Emmylou Cinco, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:45 PM
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Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Brandon Lopez conducted an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPAs were greeted and granted entry by facility licensee and administrator Emmylou Cinco after introducing themselves and stating the purpose of the visit.

The facility is an Adult Residential Facility licensed for six ambulatory clients. There are currently four clients in care. Upon arrival to the premises, two clients are observed waiting for their transportation to day program and the other two have already left. Clients are able to confirm they are on their way to day program.

The facility is a two-story home with two shared bedrooms assigned to clients. Clients share one common bathroom. There is an additional staff room on the ground level. The upper level is for use by staff only as verified during the visit and includes an additional room used for storage and a staff office. The facility's interior appears clean, safe, and sanitary. All clients’ rooms had required elements, including bed, chair, closet space, and ample lighting. Hot water measured initially below the required temperature range but licensee was able to adjust the tankless water. Water eventually measured at 112.5F in the bathroom used by clients. A consultation is provided to the licensee and documented on an attached Technical Violation Advisory Note. LPAs observed the facility had a two-day supply of perishables and a seven-day supply of non-perishable food available as required by regulations. LPAs observed hallways and walkways were free of obstructions. There are no bodies of water on the premises. There is a covered patio behind the house that is used for leisure and activities.

LPAs observed the fire extinguishers present in the living room wall are charged and have a maintenance tag dated 2024. Staff and LPAs tested smoke and carbon monoxide detectors which were found to be operational. Sharp instruments are stored in a locked drawer in the kitchen. Cleaning supplies and laundry area and products are stored in the locked garage. Medication for each client is kept locked and secured in a locked cabinet in the kitchen. CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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: EL CINCO FAMILY HOME CARE
FACILITY NUMBER: 306005229
VISIT DATE: 12/11/2024
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CONTINUED FROM LIC809
LPAs reviewed all four clients’ files and medications as well as P&I records which were verified to correspond to the amount noted on the ledgers. Receipts also match the amounts and dates logged in the ledger. LPAs reviewed two staff files. All current staff members are cleared and associated.

The Emergency and Disaster Plan was reviewed along with documentation of fire and emergency drills conducted twice in 2024 which does not follow the recommended quarterly frequency. Technical Violation Advisory Note provided..

No deficiencies are cited during today's inspection visit. Three consultations were provided on Technical Violation Advisory Notes regarding the frequency of fire drills, climate control on the premises and water temperature and regular temperature checks. An exit interview was conducted and a copy of this report was provided to the facility staff.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
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