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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005486
Report Date: 06/25/2024
Date Signed: 06/25/2024 02:32:49 PM

Document Has Been Signed on 06/25/2024 02:32 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:UNITED PEACE RESIDENTIAL HOMEFACILITY NUMBER:
306005486
ADMINISTRATOR/
DIRECTOR:
TA-PEREZ, MICHELEFACILITY TYPE:
735
ADDRESS:17552 GERALDINE LN BTELEPHONE:
(714) 375-5312
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: 4CENSUS: 4DATE:
06/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:32 PM
MET WITH:Heather Ta, Administrator & DSPTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Heather Ta. During today’s visit, LPA met with Heather Ta, Administrator & Direct Support Professional (DSP).

The facility is a level three, single story building with an approved fire clearance for four ambulatory only. The facility currently has a census of four clients in care. During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 111.5 and 111.7 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on January 2, 2024. The facility’s last disaster drill was conducted on April 15, 2024. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medication appear to be being given as prescribed.

LPA reviewed four of four staff training and fingerprint records. LPA conducted a complete review of client records. Client P&I records were reviewed and accurate. LPA interviewed staff present regarding care provided. LPA observed Client 2 (C2) preparing and leaving for work. Client 4 (C4) was resting and the other two clients were in Day Program. LPA confirmed that administrator has a pending administrator certificate which expired on March 19, 2024 but documentation was provided for renewal.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Heather Ta, Administrator and DSP and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2024
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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