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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005302
Report Date: 12/19/2019
Date Signed: 10/22/2021 11:49:05 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/22/2021 11:49 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
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:
(714) 624-9933
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: 2DATE:
12/19/2019
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Dante Benedicto, AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analysts (LPA), Kathrina Chin made an unannounced visit for the purpose of conducting a Required Annual evaluation. LPA met with Jennelyn Mortel, Danna Elizondo, Peter Nadongga, and Linda De Veyra and two clients. Jennelyn Mortel, caregiver, contacted Administrator Collantes to notify her of LPA visit. LPA Chin spoke to Delia Collantes over the telephone. Dante Benedicto, Administrator arrived at 3:20 pm. LPA confirmed AD has a current Administrator Certificate which expires 7/17/2021 and 6/9/2021.

LPAsrequested and reviewed 2 client files. Reviewed but not limited to were admissions agreement, IPP, physician's report and P & I with no concerns noted. LPA requested and reviewed staff files for all three staff who were present. Reviewed but not limited to were first aid certificates, proof of TB test, and criminal record clearance. LPA toured the facility interior and exterior along with Jennelyn Mortel. Facility was operating within the allowed capacity. All dangerous objects, toxins, and medications were kept inaccessible to all clients. Indoor and outdoor passageways were free of debris or obstructions. Adequate lighting was noted during time of visit. Hot water temperatures were tested at 132.2 degrees F in client 1's bathroom and 138.3 degrees F in bathroom 2. Client bathrooms and all hand washing areas observed to be sanitary and in good operating condition. Resident 1 bedroom is missing the required box spring and mattress per his preference. All other required linen and bedroom furniture was adequate. 6 of 6 smoke alarms and 1 of 1 carbon monoxide detectors were tested and operational during time of visit. Food Services were checked during time of visit and observed to be in compliance with regulations. The required 2 day perishable and 7 non-perishable food requirements were met. An adequate number of staff were available during time of visit. Clients were accorded with safe, healthful and comfortable accommodations. Facility last conducted a fire drill on 7/22/2019.

Based on the observations made during today’s visit, the following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Dante Benedicto, Administrator and a copy of this report was left at the facility.
SUPERVISORS NAME: Lori Bertrand
LICENSING EVALUATOR NAME: Kathrina Chin
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2019
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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Document Has Been Signed on 10/22/2021 11:49 AM - It Cannot Be Edited


Created By: Kathrina Chin On 12/19/2019 at 04:34 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: MELLS LANE HOME
FACILITY NUMBER: 306005302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2019
Section Cited
CCR
8888

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Furniture, Fixtures, Equipment, and Supplies- (e) Faucets used by clients...shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate...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).
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Dante Benedicto, Administrator lowered the hot water temperature. Mr. Benedicto stated that he will send the proof of correction by 12/23/2019.
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This regulation was not met as evidenced by: Licensee did not ensure hot water was maintained betweeen 105 and 120 degress Farhenheit in two client bathrroms. LPA tested hot water in client bathrooms at 138.2 and 132.2 Farhenheit. This poses a potential risk to clients in care.
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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:Lori Bertrand
LICENSING EVALUATOR NAME:Kathrina Chin
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2019


LIC809 (FAS) - (06/04)
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