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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005295
Report Date: 07/28/2022
Date Signed: 07/28/2022 03:41:43 PM

Document Has Been Signed on 07/28/2022 03:41 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:MAE HOUSEFACILITY NUMBER:
306005295
ADMINISTRATOR:MAI, ANNIEFACILITY TYPE:
735
ADDRESS:521 FULLERTON AVETELEPHONE:
(714) 478-5557
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92663
CAPACITY: 4CENSUS: 4DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Cherokee FoxTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Cherokee Fox and explained the reason for the visit. Administrator Annie Mai arrived during the visit. Administrator Annie Mai has an administrator certificate expiring on 02/04/2024.

At 1:05 PM, LPA toured the facility with Caregiver Fox. Facility has 4 clients in care during today's visit. LPA observed clients relaxing in the facility. All clients appeared happy and well taken care of. Facility appears clean and sanitary. All client rooms had the required elements as well as restrooms stocked with soap/ sanitizer. All rooms are single and double occupancy. Facility screens all visitors to the facility and LPA observed the screening station in the facility. Facility utilizes a visitor sign in sheet. Facility takes client temperatures daily and Caregiver provided proof of documentation. Facility has covid precaution postings as well as all required department postings. LPA observed the first aid kit has all required items. Fire extinguishers are fully charged and smoke detectors are operational. Facility mitigation plan has been submitted and is approved. Facility emergency disaster plan is posted. LPA observed an ample supply of emergency food and water. LPA toured the outside grounds and observed the shaded outside visitation area. Exit gate is unlocked and self latching. Facility has two large gardening areas for clients. LPA observed the locked medication storage area. Facility has a plan for covid testing clients and staff as needed as well as a plan for isolation and quarantine. LPA reviewed all client files during the visit and all files contained updated emergency information. Most clients and staff are vaccinated for Covid-19.

LPA consulted with Administrator regarding the importance of screening all visitors to the facility.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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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