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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005314
Report Date: 08/23/2024
Date Signed: 08/23/2024 10:59:49 AM

Document Has Been Signed on 08/23/2024 10:59 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:AXIS IFACILITY NUMBER:
306005314
ADMINISTRATOR/
DIRECTOR:		PAUL LANGFACILITY TYPE:
772
ADDRESS:1604 W SANTA ANA BLVDTELEPHONE:
(657) 247-0130
CITY:SANTA ANASTATE: CAZIP CODE:
92703
CAPACITY: 6CENSUS: 3DATE:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Jose Galang-Mental Health Worker, Ariana Crame-AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Mental Health Worker Jose Galang. Administrator (AD) Ariana Crame arrived shortly after.

For today’s visit, LPA observed a total of three clients in care and two staff members on duty.

LPA Ramirez toured the interior and exterior portions of the facility with AD Crame. The facility is a two story structure with a detached garage and is licensed for six ambulatory clients. There are a total of three bedrooms and two staff offices. LPA Ramirez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detectors were tested and operational. There are a total of four restrooms of which one is for staff. Restrooms were observed to be in good repair, to have a supply of soap, toilet paper and paper towels. LPA observed bathrooms to have hand washing signs posted. Water temperature tested between 106.5-110.4 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to clients in care. Fire extinguishers were charged, and one was located by the kitchen, one in the garage and one by the clients' bedroom hallway.

During today's visit LPA observed as the clients were having breakfast and watching television.

CONTINUED ON LIC809-C...

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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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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: AXIS I
FACILITY NUMBER: 306005314
VISIT DATE: 08/23/2024
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LPA Ramirez observed the emergency disaster and evacuation plan which is located by the stairway to the second floor. Facility had back-up emergency food and water supply. LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to clients in care.

For the exterior portion, LPA Ramirez observed a shaded patio area with furniture, and the grounds were free of any hazards. There are no two gates in the backyard. No bodies of water were observed.

LPA reviewed three client files and two staff files. LPA interviewed clients and staff present.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with AD Crame.

A copy of this report was provided at the time of exit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
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