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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005554
Report Date: 07/11/2024
Date Signed: 07/11/2024 11:58:39 AM

Document Has Been Signed on 07/11/2024 11:58 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:DEVOTED HEART CARE HOMES LLCFACILITY NUMBER:
306005554
ADMINISTRATOR/
DIRECTOR:		KEVIN CLARKFACILITY TYPE:
735
ADDRESS:26665 AVENIDA SHONTOTELEPHONE:
(818) 384-9331
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 4CENSUS: 4DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Laura Palomino- AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual inspection using the Care Inspection Tool. LPA met with Administrator Laura Palomino and explained the purpose of the visit.

The facility is a two story structure in a residential neighborhood. There are four client bedrooms and two bathrooms. The facility offers a service level 4G.

LPA Cho toured the interior and exterior of the facility with the Admin. The facility appeared to be clean and operational. LPA observed the required department postings throughout the facility. There is a minimum of one week of non-perishable and two day perishable food available. The facility is maintained at a comfortable temperature. LPA observed medications are centrally stored in a locked safe in the storage closet located in the hallway. LPA measured the hot water temperature which measured at 118.5 and 118.9 degrees Fahrenheit. All bathrooms were observed to have a supply of soap, toilet paper, and clean towels. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxins, cleaning solutions, and disinfectants are stored locked in the garage. The facility has extra supply of clean linens. LPA inspected the clients' bedrooms which has sufficient lighting to ensure safety and comfort. All bedrooms observed to have all required components. Storage space is provided for clients in their bedroom. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. The exit gates were self-closing and self-latching. LPA observed sufficient seating and shading. LPA observed the fire extinguisher was mounted, charged, and serviced on September 5, 2023. The auditory devices, carbon monoxide, and smoke detectors were tested and operational. LPA observed the required 'See Something, Say Something' (PUB475) poster in the living room area.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: DEVOTED HEART CARE HOMES LLC
FACILITY NUMBER: 306005554
VISIT DATE: 07/11/2024
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LPA conducted an audit of four clients' files and two personnel files. No discrepancies noted with the file review. LPA conducted two interviews with staff. Client interviews were not conducted as clients were in the day program. Medications were audited. No discrepancies noted.

Based on the observations made during today's visit, no deficiency is being cited today.

An exit interview was conducted with Administrator Laura Palomino, and a copy of this report was provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC809 (FAS) - (06/04)
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