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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005302
Report Date: 12/12/2023
Date Signed: 12/12/2023 11:59:04 AM

Document Has Been Signed on 12/12/2023 11:59 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 ASC, 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:
12/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Dante Benedicto - AdministratorTIME COMPLETED:
12:15 PM
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LPAs Dwayne Mason Jr. and Ruth Martinez arrived at the facility to conduct a case management visit regarding incident reports turned in by the facility. LPAs were greeted by Administrator (AD) Dante Benedicto and stated the purpose of the visit. LPAs were granted entry.

LPAs observed all three residents to be home at the facility lounging, watching TV and helping in the kitchen. LPAs met with AD to discuss and review documents surrounding three special incident reports submitted in November 2023 regarding: Staff trying to sell an iPad to client, An unreported hit-and-run accident the client experienced, Accusations of financial abuse from a former staff member to client.

1. AD stated the iPad still has not been located. The iPad belonged to a different client and the facility is taking steps to replace the device. AD stated they will implement a sign-in/sign-out system for the facility device in the future.
2. AD stated that the accident went unreported because the client and their mom did not report the accident to staff. On the day of the accident, the client was out in the community attending school and returned to facility close to the time they normally return home and did not tell staff of the incident. Facility was not made aware until late November at the clients annual meeting. No injury were noted on the day of the incident.
3. AD stated that they have decided to terminate the staff member accused of financial abuse. LPAs verified this based on the current staff schedule which does not list the former staff member accused of financial abuse. AD also stated that the resident has their own phone and chooses to keep in contact with the accused former staff member. LPAs reviewed IPP to confirm resident manages own money.

Based on interview with AD, review of text messages between the resident and former staff member and file review, LPAs have determined the facility followed protocol to the best of their ability regarding the three aforementioned incidents. No deficiency is being cited and a copy of this report was provided to the facility. Report reviewed with Administrator.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023
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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