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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005486
Report Date: 05/31/2022
Date Signed: 05/31/2022 01:46:00 PM

Document Has Been Signed on 05/31/2022 01:46 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:UNITED PEACE RESIDENTIAL HOMEFACILITY NUMBER:
306005486
ADMINISTRATOR:TA-PEREZ, MICHELEFACILITY TYPE:
735
ADDRESS:17552 GERALDINE LN BTELEPHONE:
(714) 375-5312
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: 4CENSUS: 4DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Administrator, Heather TaTIME COMPLETED:
02:05 PM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was granted entry into the facility by staff. LPA Tirre met with Administrator Heather Ta and explained the reason for the visit.

During the visit LPA toured the facility with Administrator. Facility is a 3 bedroom and 2 bathroom single story home. There are 4 Clients in care. LPA observed proper covid signage at front entrance of facility as well as sanitization and temperature check station. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring November 12, 2023. LPA toured all clients rooms, all rooms had required Furnishings per regulations. All restrooms observed contained working wash basin, soap, wipes, sanitizer, toilet paper and towels. Restrooms had proper hand washing signs posted. Clients were observed relaxing in bedrooms.

Facility has ample supply of PPE. LPA observed facility has emergency food and water supply. Facility has required Emergency Disaster Plan posted. Facility has a secured location for Client medication and files. Facility has 30 days supply of medications for clients. LPA reviewed Clients files during visit. 4 of 4 clients files were observed. Clients emergency contact information and Physicians reports are current. Facility has 1 fire extinguisher that is fully charged and mounted. Facility has operating smoke detectors and carbon monoxide detectors in client rooms, hallway, kitchen and living room areas. Facility has a designated visitation area.

No deficiencies or advisories were found during this visit.

An exit interview was conducted with Administrator Heather Ta and copy of report was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2022
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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