306005362-2-13-2025-22-AS-MTEA-DDUR5F-20250213114303

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005362
Report Date: 02/13/2025
Date Signed: 02/13/2025 11:43:12 AM

Document Has Been Signed on 02/13/2025 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:	LP CARE HOME		FACILITY NUMBER:	306005362
ADMINISTRATOR/ DIRECTOR:	TRAN, LINDA		FACILITY TYPE:	735
ADDRESS:	8791 MONTEREY CIRCLE		TELEPHONE:	(714) 622-5764
CITY:	WESTMINSTER	STATE: CA	ZIP CODE:	92683
CAPACITY: 6		CENSUS: 5	DATE:	02/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Phil Tran		TIME VISIT/ INSPECTION COMPLETED:	11:58 AM

NARRATIVE

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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by Direct Service Personnel (DSP) Marie Voelker. Administrator (AD) Phil Tran arrived shortly to assist with the visit. The facility is licensed for 6 ambulatory clients. Currently there are 5 clients living here during today's visit.

LPA Tea reviewed five client files and two staff files. Client files and staff files contained all required documentation. The administrator certificate expires on April 19, 2026.

LPA Tea along with the administrator toured the facility at 9:47 AM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a two-story home with four client bedrooms, one staff room, and three bathrooms. The facility has a kitchen, dining room, family room, staff office area, and living room with an attached garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure. Water temperature measured between 115.3F degrees and 123.0 F degrees. Administrator posted signs in the bathroom for the hot water temperature to caution clients. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit.

Continuation of annual report on LIC809C

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

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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Document Has Been Signed on 02/13/2025 11:43 AM - It Cannot Be Edited

Created By: Michael Tea On 02/13/2025 at 11:07 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: LP CARE HOME	FACILITY NUMBER: 306005362
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation during facility tour, downstairs bathroom has some mildew that needs to be cleaned. 3 stove burners didn't work properly without the use of an ignitor. This could pose as a potential health and safety risk to clients in care.
	POC Due Date: 02/27/2025
	Plan of Correction
1 2 3 4	Replace or repair stove and provide proof to LPA by POC due date and provide proof of bathroom clean up to LPA by POC due date.

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.

SUPERVISOR'S NAME:

Alisa Ortiz

LICENSING EVALUATOR NAME:

Michael Tea

LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

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: LP CARE HOME	FACILITY NUMBER: 306005362
	VISIT DATE: 02/13/2025

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LPA observed sharps locked with the medication in a cabinet in the kitchen. LPA also observed toxin substances to be secured and locked and inaccessible to clients in a storage closet in the garage. Fire extinguishers are fully charged throughout the facility. The facility’s last fire drill was conducted on January 29, 2025. Kitchen stove had problems with the burners operating properly. LPA toured the outside grounds and there is ample seating with shade. LPA observed emergency supplies, food, and water in the front entryway closet. LPA Tea observed clients watching television and eating breakfast. The staff provide activities based on client’s personal preference such as outings and going to church.

At 10:12 AM LPA reviewed medication storage and administration. Medications are stored in a locked cabinet in the kitchen. Medications are being administered per physician order. P&I Funds were checked and meet department standards. LPA interviewed clients regarding their quality of care and spoke to staff present regarding care provided.

Based on the observations made during today’s visit, the following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Administrator Phil Tran and a copy of these reports were given to the facility along with a copy of the LIC 858; 859;809-D, and Appeal Rights.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

LIC809 (FAS) - (06/04)

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