<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005301
Report Date: 07/29/2024
Date Signed: 07/29/2024 04:10:52 PM

Document Has Been Signed on 07/29/2024 04:10 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:AMHS TELECARE TREEHOUSE CRISIS RESIDENTIAL-SOUTHFACILITY NUMBER:
306005301
ADMINISTRATOR/
DIRECTOR:		ANTONIO RESENDIZFACILITY TYPE:
772
ADDRESS:25402 PACIFICA AVENUETELEPHONE:
(949) 238-2400
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 1DATE:
07/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Tamara Nabulsi, Clinician
Antonio Resendiz, Program Director		TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On this day, Licensing Program Analysts (LPA) Kevin Saborit-Guasch & William Vanegas made an unannounced visit to the facility for the purpose of conducting a Required Annual Inspection. LPAs were greeted and granted entry by facility staff after introducing himself and stating the purpose of the visit. Clinician Tamara Nabulsi was present at the facility and Clinical Director Antonio Resendiz arrived later to assist with the visit.

During the inspection, LPAs accompanied by staff conducted a tour of the inside and outside of the facility:
The facility is a two-story house with there shared client bedrooms and one shared bathroom on each level in addition to a therapy office, a staff office and common areas. All client bedrooms had the required furnishings. LPAs observed all client beds had linens and blankets. Bathrooms faucets and toilets were operational. Water temperature tested to be within the appropriate temperature range. LPAs observed all windows were screened and not equipped with security window bars. The backyard has a shaded sitting area equipped with outdoor furniture. There is a pool present which is fenced and accessible only upon client request with staff supervision. One client is admitted to the facility and present at the time of the visit.

LPAs observed and reviewed the facility's emergency disaster plan with means of exiting and emergency phone numbers listed and posted in the facility's hallway. Menu was also posted and visible. Meals are catered by a chef for lunches and dinners on weekdays and dinners on week-ends. LPAs observed the facility does have 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 extinguishers were observed to be fully charged. Sharps were observed to be kept locked and inaccessible. All and any toxic chemicals, cleaning solutions, laundry detergent and disinfectants are also inaccessible to clients. Laundry detergent is available to client for personal laundry upon request with staff supervision.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2024
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 3
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: AMHS TELECARE TREEHOUSE CRISIS RESIDENTIAL-SOUTH
FACILITY NUMBER: 306005301
VISIT DATE: 07/29/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
CONTINUED FROM FORM LIC809

Medication cabinet was observed to be locked in staff room. LPAs reviewed one client file and four staff files for staff members present at the time of the visit. One staff member was observed to have a background check under a different name after a personal name change. Background clearance was verified but there had been no granted transfer of clearance to the present licensed facility from AMHS Telecare Treehouse - North (license # 306005412). LPAs interviewed two staff members and one client during the visit.

Based on the observations made during the visit, one type B deficiency was cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/29/2024 04:10 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 07/29/2024 at 03:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AMHS TELECARE TREEHOUSE CRISIS RESIDENTIAL-SOUTH
FACILITY NUMBER: 306005301

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 81019(f); or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on a review of staff records at the facility, the licensee did not comply with the section cited above as one staff member was observed to be associated to a different licensed location operated by the licensee. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2024
Plan of Correction
1
2
3
4
Licensee to submit a request of clearance transfer or proceed to association of the staff member in question in Guardian and submit proof thereof to LPA before the plan of corrections due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3