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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005516
Report Date: 11/13/2023
Date Signed: 11/13/2023 01:14:29 PM

Document Has Been Signed on 11/13/2023 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ST. IRENEUS CARE VILLAFACILITY NUMBER:
306005516
ADMINISTRATOR:ALIPIO JR, IRENEO DFACILITY TYPE:
735
ADDRESS:10030 HOLDER STTELEPHONE:
(714) 699-1327
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 4CENSUS: 4DATE:
11/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Assistant Administrator - Neomi GolfoTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived for an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by DSP Patrick Florendo. Assistant Administrator Neome Golfo joined the inspection at approximate 11:30am.

The facility is a one-story home with four resident bedrooms, four resident bathrooms, kitchen, dining room, living room, staff room, additional kitchen, back yard and attached two-car garage. LPA noted that one resident was away at day program during visit. Facility appears clean and sanitary. All residents rooms had required elements, including bed, chair, closet space and ample lighting. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured at 112.8 degrees Fahrenheit in the bathroom in bedroom 1, 110.6 degrees Fahrenheit in the bathroom accessible from bedroom 2, 111 degrees Fahrenheit in the bathroom in bedroom 3 and 112.8 degrees Fahrenheit in the common bathroom. Facility has a supply of extra linen and hygiene supplies stored in the garage. LPA observed facility has emergency food and water supply stored in the garage. Backyard has one shaded seating area and several plants. Facility also has an additional kitchen that is kept locked in the backyard. This kitchen is used to prepare food for BBQs/backyard activities. Both exit gates in the backyard are operational and accessible. Medication, first aid kit and facility files are stored in locked cabinets in the dining area/kitchen. LPA reviewed all four resident files and four personnel files. LPA reviewed all medication with DSP Florendo. Medication appears to be appropriately stored and correctly administered by qualified staff. LPA reviewed P&I with DSP Florendo. P&I was reviewed, accounted for and appeared to be documented properly. LPA interviewed the only resident available for interview.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was provided to the assistant administrator.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2023
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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