306005359-1-9-2025-22-AS-WVAS-DCRSVG-20250109131244

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005359
Report Date: 01/09/2025
Date Signed: 01/09/2025 01:14:21 PM

Document Has Been Signed on 01/09/2025 01:14 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:	CLOSE TO HOME SENIOR CARE III		FACILITY NUMBER:	306005359
ADMINISTRATOR/ DIRECTOR:	PARNELL, MARICAR		FACILITY TYPE:	740
ADDRESS:	1148 E CHESTNUT AVE		TELEPHONE:	(714) 872-0965
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	01/09/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Charito De Ocampo		TIME VISIT/ INSPECTION COMPLETED:	01:30 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	On 01/09/2025 Licensing Program Analyst (LPA) William Vanegas made an unannounced visit for the purposes of an annual inspection. Upon arrival LPA Vanegas was greeted and granted entry by Care Giver (CG) Charito De Ocampo. LPA Vanegas explained the purpose of the visit, and was advised that administrator would arrive shortly. LPA Vanegas began a tour of the facility and observed the following. This is a one storied home with six bedrooms one of which is a caregiver room, and two bathrooms used for residents and a two car detached garage. LPA Vanegas observed kitchen area to be clean and free of debris and observed a gas stove, microwave, refrigerator, and dishwasher that were all operational and in good repair. LPA Vanegas observed a two day supply of perishable food, and a seven day supply of non-perishable food along with a sufficient amount of emergency water. LPA Vanegas observed resident restrooms to be clean and free of debris and contained all the proper furnishings such as grab bars, slip resistant matts, and a shower chair. Toilet and water faucets tested functional and water tested between 117.2-118.4 degrees. LPA Vanegas observerd fire extinguisher to be fully charged and up to date. LPA Vanegas observed all smoke detectors and carbon monoxide detectors to be operational. LPA Vanegas observed washer and dryer to be operational and in good repair and all detergents were locked away and inaccessible to residents in care. LPA Vanegas toured the backyard of the facility and observed a seated shaded area, and enough space for residents to participate in outdoor activities upon their request. LPA Vanegas observed no obstructions along emergency exit route, and side doors are self latching and unlocked. LPA Vanegas toured the garage and observed organized and clean personal items belonging to caregivers and licensee. CONTINUED ON LIC809C

Armando J Lucero	TELEPHONE: (714) 703-2866
William Vanegas	TELEPHONE: (714) 497-7621
	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

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: CLOSE TO HOME SENIOR CARE III	FACILITY NUMBER: 306005359
	VISIT DATE: 01/09/2025

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LPA Vanegas reviewed four resident files and observed the following. Three of four resident files had all the required documentation however one of the four files did not have a signed consent form for emergency medical attention. Licensee was able to contact responsible party and obtain signed consent form before LPA Vanegas ended the visit. A technical advisory was issued on today's date. LPA Vanegas reviewed two staff files and observed all staff files to have the required documentation filed and the required annual training completed.

LPA Vanegas observed medications to be locked away and inaccessible to clients in care. LPA Vanegas reviewed medications and observed medications being documented and being administered to clients in care per physicians orders. LPA Vanegas interviewed one client in care who was coherent and verbal. LPA Vanegas interviewed one staff on duty.

LPA Vanegas observed emergency disaster plan to be filled out and up to date and reviewed, LPA Vanegas observed infection control plan to be up to date and reviewed. LPA Vanegas observed all required postings to be posted and in the correct dimensions. LPA Vanegas observed first aid kit and it consisted of all the required equipment including adhesive tape, scissors, a thermometer, and bandages.

Based on the observations made during today’s inspection, deficiencies are not being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2866
LICENSING EVALUATOR NAME: William Vanegas	TELEPHONE: (714) 497-7621
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC809 (FAS) - (06/04)

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