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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005323
Report Date: 10/30/2024
Date Signed: 10/30/2024 11:43:30 AM

Document Has Been Signed on 10/30/2024 11:43 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:CONGREGATE CARE TOUCHFACILITY NUMBER:
306005323
ADMINISTRATOR/
DIRECTOR:
CRUZ, CHONAFACILITY TYPE:
740
ADDRESS:238 SAN CARLOS WAYTELEPHONE:
(714) 646-9302
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
10/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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Licensing Program Analysts (LPAs) Samer Haddadin and Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPAs met with staff Hyannie "Irish" Arceno and discussed the purpose of the inspection. During the inspection LPAs conducted a tour of the inside and outside of the facility, common areas, residents’ rooms, kitchen, garage and observed the following:
This is a single-story house with six bedrooms, and three bathrooms, with one bedroom being occupied by staff. During the inspection LPAs observed two staff and five residents in care. Two Residents were observed eating in the dining room, one resident was exercising in living area, and two residents were watching television in their respective bedrooms. LPAs observed smoke detectors/carbon monoxide in common areas and bedrooms; all were tested and were operational. Residents’ bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Toilets and water faucets were observed to be operational, grab bars were secure, and shower was free of mold/mildew. Water temperature was tested in first bathroom and measured at 112.2 degrees Fahrenheit. The second restroom measured at 114.00 degrees Fahrenheit.Food supplies: A two-day supply of perishable and a seven-day supply of non-perishable food was observed during today’s visit. LPAs reviewed staff files and residents’ files and found all files had all required documents.

Fire extinguisher was fully charged with service tag indicating last inspection date was on June 27th,2024. The facility’s last fire drill was conducted on August 19th,2024 and Administrator (AD) conducts drills every three months. Kitchen appliances were operational during today's visit; all knives and sharps were locked in kitchen drawer. LPAs toured the backyard and observed there was a shaded seating area. LPAs also checked Administrator certificate and noted to be active with expiration date of December 10th, 2024.Administrator (AD) Arvin Bumanglag arrived at approximately 10:01 AM. No deficiencies were noted during today's inspection visit. An exit interview was conducted, and a copy of this report was provided to the administrator.

Alisa OrtizTELEPHONE: (714) 703-2855
Samer HaddadinTELEPHONE: (714) 790-2096
DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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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