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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005302
Report Date: 02/22/2024
Date Signed: 02/22/2024 10:50:52 AM

Document Has Been Signed on 02/22/2024 10:50 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:
(657) 230-9766
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: 3DATE:
02/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Delia Collantes - AdministratorTIME COMPLETED:
10:59 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley made an unannounced Case Management visit. LPA Haley was greeted and granted entry by staff and explained the reason for the visit.

During the investigation of complaint control # 22-AS-20231204113932 additional violations were discovered.

During interviews with the Administrator and Assistant Administrator it was discovered that Client 1 (C1) was staying overnight at the client’s mothers home without giving proper notice and receiving approval from C1’s public defender as required in the clients IPP.

A review of C1’s IPP dated November 21, 2022, page 8, detail the instructions and plan C1 is to follow when spending time with family since C1 is not supervised by the court or the home (Mells Lane Home) during those visits.

As a result of today’s Case Management visit, deficiencies will be cited.

An exit interview was conducted and a copy of this report, LIC809D, and appeal rights were provided.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024
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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Document Has Been Signed on 02/22/2024 10:50 AM - It Cannot Be Edited


Created By: Jerome Haley On 02/22/2024 at 10:18 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: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/29/2024
Section Cited
CCR
80063(a)

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80063 Accountability
(a) The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation.
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Administrator Collantes agrees to review regulation section 80063, send a signed statement of acknowledgment and understanding upon completion. Administrator Collantes will send a detailed outline of the steps that will be taken whenever an unauthorized visit occurs in the future. The POC will be emailed to LPA Haley by Thursday, February 29, 2024 at 1:00PM.
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This requirement has not been met as evidenced by a client staying overnight at the client's mothers home without required approval from the clients public defender as covered in the clients IPP.
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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:Luz Adams
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024


LIC809 (FAS) - (06/04)
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