306005336-1-14-2025-22-AS-LMAZ-DCWRR2-20250114121424

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005336
Report Date: 01/14/2025
Date Signed: 01/14/2025 12:15:46 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/14/2025 12:15 PM - 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:	CASA DE LOS ARBOLES		FACILITY NUMBER:	306005336
ADMINISTRATOR/ DIRECTOR:	ROY SWEENY MD		FACILITY TYPE:	740
ADDRESS:	6482 VIA ARBOLES		TELEPHONE:	(714) 673-0032
CITY:	ANAHEIM HILLS	STATE: CA	ZIP CODE:	92807
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	01/14/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:15 AM
MET WITH:	Marlawm Logrono		TIME VISIT/ INSPECTION COMPLETED:	12:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	This LIC809 was created at 3:00pm on 01/13/2025. LPA arrived to the facility at 8:30am and ended the visit at 10:45am. LPA conducted the Required-1 Year visit but was unable to open a Facility Evaluation Report (LIC809) due to Program being down. The following was provided to Administrator Irvin Harris on the attached Word document: Facility Name: Casa De Los Arboles Time Began: 8:30am Administrator: Roy Sweeny Time End: 10:45am Address: 6482 Via Arboles, Anaheim Hills, CA 92807 Capacity: 6 Census: 5 Type of Visit: Required 1-Year Met With: Irvin Harris C. Mendoza ------------------------------------------------------------------------------------------------ Licensing Program Analyst (LPA) Lydia Martinez made an unannounced Required 1 – Year inspection at this facility. LPA introduced herself and stated the purpose of the visit. LPA was granted entry into the facility by Caregivers Rodelio Manalo and Marlawm Logrono. Administrator Irvin Harris arrived shortly after. LPA, along with AD Harris conducted a tour of the inside and outside of the facility. LPA spoke with 3 of the 5 residents during today’s visit. LPA observed residents to be clean and warm. Facility was observed to be clean and in good repair and is kept at a comfortable temperature for the residents in care. LPA reviewed 5 resident files and 2 staff files during today’s visit. Medication was observed to be in a centrally stored location and medication reviewed appeared to have been dispensed accurately. Due to computer glitch, LPA is unable to leave a Facility Evaluation Report (LIC809). LPA reviewed this report with AD Harris and copy was sent to AD's email for signature. (see LIC809C)

Lourdes Montoya	TELEPHONE: (714) 748-2936
Lydia Martinez	TELEPHONE: (714) 705-6004
	DATE: 01/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

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: CASA DE LOS ARBOLES	FACILITY NUMBER: 306005336
	VISIT DATE: 01/14/2025

NARRATIVE

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On 01/14/2025, there are 5 Residents and 3 staff present during the visit. One resident is receiving Hospice care. LPA toured the physical plant. LPA observed the facility to be clean, sanitary and in good repair. The home is maintained at a comfortable temperature. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each Resident comfortably. Bathrooms were checked, toilets/water faucets worked properly and shower was free of mold/mildew. Hot water temperature was within regulatory requirements. Bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Kitchen is clean and organized. Perishable and non-perishable food supply was checked and adequately stocked. LPA observed sharps and cleaning supplies are inaccessible to the Residents. Smoke detectors and carbon monoxide detector tested operational; Fire extinguisher was fully charged and mounted. No bodies of water were observed outside. Walkways around the home were clear of hazards. Exit gates are unlocked and self-latching. Patio table with chairs was observed. There is no record of Emergency/Fire Drills being conducted. LPA observed emergency supplies, including food and water.

LPA observed a twin bed and personal belongs in storage room connected to the dining room. Per AD, room is being used as a staff room. LPA observed the half of the single car garage was converted into a staff room and office. The Fire Clearance granted on 12/14/2017 states "Garage shall be used for vehicles only. Garage shall not be used for any habitable space."

Based on observations made during the visit conducted on 01/13/2025 the following deficiency is being cited. This report was discussed with the facility Representative and a copy of LIC809, LIC809C, LIC809D Appeal Rights were sent to email on file.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 705-6004
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 01/14/2025 12:15 PM - It Cannot Be Edited

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: CASA DE LOS ARBOLES	FACILITY NUMBER: 306005336
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Fire Safety - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 01/15/2025
	Plan of Correction
1 2 3 4	Licensee will immediately cease using garage as staff bedroom by close of business day of 01/15/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Lourdes Montoya	TELEPHONE: (714) 748-2936
Lydia Martinez	TELEPHONE: (714) 705-6004
	DATE: 01/14/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 01/14/2025 12:15 PM - It Cannot Be Edited

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: CASA DE LOS ARBOLES	FACILITY NUMBER: 306005336
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter...An actual evacuation of residents is not required... Documentation of the drills shall include the date...This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 01/17/2025
	Plan of Correction
1 2 3 4	Licensee to review section cited, self certify understanding. Will conduct a drill by 01/17/2025 and submit proof to LPA. Licensee to ensure quarterly drills are conducted and documented.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Lourdes Montoya	TELEPHONE: (714) 748-2936
Lydia Martinez	TELEPHONE: (714) 705-6004
	DATE: 01/14/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC809 (FAS) - (06/04)

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