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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005302
Report Date: 10/04/2022
Date Signed: 10/04/2022 12:12:06 PM

Document Has Been Signed on 10/04/2022 12:12 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:MELLS LANE HOMEFACILITY NUMBER:
306005302
ADMINISTRATOR:COLLANTES, DELIA BFACILITY TYPE:
735
ADDRESS:1658 W MELLS LANETELEPHONE:
(657) 230-9766
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: 3DATE:
10/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:Dante Benedicto, John VillanuevaTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with Assistant Administrator Dante Benedicto and stated the purpose of this visit.

The facility is a single level structure and licensed for a capacity of six clients one ambulatory and five non-ambulatory. This facility offers care for Adult Residential.

At about 10:27 am, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed two clients in care and two staff members on duty. LPA toured the interior and exterior portions of the facility. There were three private client rooms and three staff rooms. Staff rooms were inaccessible to clients. Client rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors and carbon monoxide alarms were tested to be operational. Bathrooms were observed to be in good repair and hot water was measured between 130.2 degrees – 131.1 degrees Fahrenheit. Assistant Administrator was made aware of this citation and will have water temperature adjusted. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements, cleaning supplies were inaccessible to clients in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. Backyard had several fruit trees in good condition. LPA noticed gate in the backyard did not close properly and was not self-latching. Assistant Administrator will have backyard gate repaired. Facility offers a 2-car garage mainly used for storage with a freezer and an operational washer and dryer. Kitchen was in good repair. LPA was made aware of lock for knifes drawer breaking earlier in the day. Assistant Administrator will have lock replaced. Medications and toxins were locked and kept away from clients.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MELLS LANE HOME
FACILITY NUMBER: 306005302
VISIT DATE: 10/04/2022
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LPA Tapia was not able reviewed the COVID 19 mitigation plan but was able to review the Emergency Disaster Plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, one deficiency was noted in areas observed and three advisories were issued.

LPA Tapia conducted an exit interview with Assistant Administrator Dante Benedicto and a copy of this report was explained and left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
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Document Has Been Signed on 10/04/2022 12:12 PM - It Cannot Be Edited


Created By: Edward Tapia On 10/04/2022 at 11:51 AM
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: MELLS LANE HOME
FACILITY NUMBER: 306005302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)


This requirement is not met as evidenced by:

Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 restrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2022
Plan of Correction
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Administrator will submit proof of water tempature correction by 10/05/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Edward Tapia
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022


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