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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005295
Report Date: 09/17/2024
Date Signed: 10/23/2024 11:24:49 AM

Document Has Been Signed on 10/23/2024 11:24 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/
DIRECTOR:		MAI, ANNIEFACILITY TYPE:
735
ADDRESS:521 FULLERTON AVETELEPHONE:
(714) 478-5557
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92663
CAPACITY: 4CENSUS: 4DATE:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:03 PM
MET WITH:Jennifer Vargas, Direct Service Provider
Sandra Aguilar, Direct Service Provider		TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility staff after introducing himself and stating the reason of the visit.

During the inspection, LPA and staff conducted a tour of the physical plant and observed the following: The facility is a one-story home with one shared and two private bedrooms in addition to the facility's common living areas. There is one shared bathroom, which was observed to be equipped with grab bars and slip mats. All resident bedrooms have the required furnishings. LPA observed all beds have linen and blankets. No postural support in use.

There are currently four clients admitted to the facility, all of which are ambulatory. One client is away on vacation. The other clients are observed relaxing at the house or returning from work or day progran during the visit. Bathrooms faucets and toilets are operational. Water temperature are verified to be within acceptable range by staff on a daily basis. Fire and emergency drills are conducted quarterly and documented. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food. The facility's main fridge and freezer is undergoing repairs and a smaller, temporary refrigerator is in use. A technician was observed to perform repairs during the visit. Smoke and carbon monoxide detectors tested operational. Fire extinguishers present are fully charged with up-to-date maintenance tags attached.

There is adequately shaded outside space with outdoor furniture present in addition to raised beds for gardening activities. There are two self-latching gates allowing to exit the premises. The route of egress is free of obstructions. There are no bodies of water on the premises.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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: MAE HOUSE
FACILITY NUMBER: 306005295
VISIT DATE: 09/17/2024
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CONTINUED FROM FORM LIC809
There is a computer for use by clients in the facility's living room. The clients' Personal and Incidental ledgers and funds were reviewed and confirmed to be accurately kept. Relevant receipts are archived.

LPA reviewed four client files and eight staff files. Client records include all necessary components. All staff members are confirmed to be cleared and associated with this particular licensed location. Current CPR training and Direct Service Professional training on file as well.

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. One Technical Assistance advisory notes is provided with a consultation on the required Infection Control Plan, HIV/TB training Emergency and Disaster Plan.

An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC809 (FAS) - (06/04)
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