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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005295
Report Date: 09/28/2023
Date Signed: 09/28/2023 10:56:45 AM

Document Has Been Signed on 09/28/2023 10:56 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: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:
09/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Megan ParrishTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility was greeted and granted entry by Megan Parrish, Direct Support Professional and LPA explained the nature of the visit.

Four clients reside at this facility, LPA was informed two clients were out in the community. There was two client at the time of visit. LPA accompanied with Direct Support Professional began the tour of the inside and outside of the facility. LPA observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. The facility is maintained at a comfortable temperature. LPA inspected that medication are centrally stored in a safe locked storage cabinet located in kitchen. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care. LPA measured the hot water temperature which measured 112.6 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. The toxic chemicals, cleaning solutions and disinfectants are stored locked underneath the kitchen sink. The facility has an available clean supply of linens. LPA inspected client’s bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for clients in their bedroom. LPA observed the smoke detectors, and they were found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there is shaded seating areas for client’s enjoyment. LPA observed a fire extinguisher with service date of June 07, 2023, in kitchen. Fire drills are conducted monthly. LPA began review of records. LPA reviewed four clients’ records. All the required documentation was present and current in client’s files reviewed. The facility P&I records were reviewed. LPA observed that an individual log is maintained for each client. All monies are accounted for and attached receipts for record keeping. LPA

Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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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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: MAE HOUSE
FACILITY NUMBER: 306005295
VISIT DATE: 09/28/2023
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reviewed one employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate. LPA as a reminder provided annual fee dues information.

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 the facility representative and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC809 (FAS) - (06/04)
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