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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005605
Report Date: 08/23/2023
Date Signed: 08/23/2023 03:03:57 PM

Document Has Been Signed on 08/23/2023 03:03 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:SOCAL EMPOWERED LLCFACILITY NUMBER:
306005605
ADMINISTRATOR:JAMES PERRAIEFACILITY TYPE:
772
ADDRESS:22602 COSTA BELLA DRTELEPHONE:
(949) 701-3551
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 6DATE:
08/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Lisa McCurryTIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Case Manager (CM) Melanie Mitovich and discussed the purpose of the inspection. Clinical Director (CD) Lisa McCurry arrived at 9:52 a.m.

During the inspection LPA and CM conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a two-story house with four client bedrooms, three bathrooms, and one staff office. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. The back yard has a shaded sitting area. LPA observed two staff and six clients present. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 112.1-112.8 F degrees.

LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted in the hallway of the facility. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. All facility appliances were inspected and found to be operational. Sharps were observed locked and inaccessible. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are also locked and inaccessible to clients. Medication cabinet was observed to be locked and locks are operational. Record review of client cash resources log indicated accurate records are not being maintained; a Deficiency was cited on today's date. Facility disaster drill log indicated last disaster drill was conducted on 6/22/23. LPA reviewed six client files and five staff files. LPA interviewed four clients and two staff. (Cont. LIC809-C)
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2023
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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Document Has Been Signed on 08/23/2023 03:03 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 08/23/2023 at 01:24 PM
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: SOCAL EMPOWERED LLC
FACILITY NUMBER: 306005605

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81026(h)
Safeguards for Cash Resources, Personal Property, and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as accurate records of client cash resources are not being maintianed, which poses a potential personal rights risk to persons in care.
POC Due Date: 09/22/2023
Plan of Correction
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Clinical Director (CD) stated staff training will be conducted regarding maintaining accurate records of client cash resources and an audit will be conducted weekly to ensure accurate records are being maintained. CD stated they would provide LPA with staff training sign-in sheet and log used to conduct weekly audits via email by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023


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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SOCAL EMPOWERED LLC
FACILITY NUMBER: 306005605
VISIT DATE: 08/23/2023
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Based on the observations made during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
LIC809 (FAS) - (06/04)
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