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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005605
Report Date: 07/19/2024
Date Signed: 07/19/2024 01:12:42 PM

Document Has Been Signed on 07/19/2024 01:12 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:SOCAL EMPOWERED LLCFACILITY NUMBER:
306005605
ADMINISTRATOR/
DIRECTOR:		JAMES PERRAIEFACILITY TYPE:
772
ADDRESS:22602 COSTA BELLA DRTELEPHONE:
(949) 701-3551
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 4DATE:
07/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Nicolette Munoz, Clinical Director
Sue Kue, Charge Nurse/Program Director		TIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit for the purpose of conducting the facility's Required Annual Inspection. LPA was greeted and granted entry by facility staff after introducing himself and stating the purpose of the visit. Clinical Director Nicolette Munoz arrived later to assist with the visit.
During the inspection LPA accompanied by staff conducted a tour of the inside and outside of the facility:
The facility is a two-story house with two shared client bedrooms (one of which has an en-suite bathroom as well) and two private bedrooms, a therapy room, a medication room, one client bathroom upstairs and one staff bathroom downstairs. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. Bathrooms faucets and toilets were operational. Water temperature tested to be within the appropriate temperature range. LPA observed all windows were screened and not equipped with security window bars. The back deck has a shaded sitting area equipped with outdoor furniture. Clients were out of the facility when LPA arrived to the facility and returned during the visit.

LPA observed and reviewed the facility's emergency disaster plan with means of exiting and emergency phone numbers listed and posted in the facility's hallway. Menu was also posted and visible. Meals are catered by a chef for lunches and dinners on weekdays and dinners on week-ends. LPA observed the facility does have 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 extinguishers were observed to be fully charged. Sharps were observed to be kept locked and inaccessible. All and any toxic chemicals, cleaning solutions, laundry detergent and disinfectants are also inaccessible to clients. Medication cabinet was observed to be locked in medication room. LPA reviewed four client files and five staff files. LPA interviewed three staff members and two clients during the visit, two other clients declined.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2024
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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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: SOCAL EMPOWERED LLC
FACILITY NUMBER: 306005605
VISIT DATE: 07/19/2024
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CONTINUED FROM FORM LIC809
Background clearance, training records, driving licenses and first aid training were verified for five staff members. All staff members present are cleared and associated to the facility.

Based on the observations made during today’s inspection, one type B 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 along with appeal rights was left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/19/2024 01:12 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 07/19/2024 at 01:01 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: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell in a residential facility serving adults, on or before July 1, 2021.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation conducted during the tour of the physical plant, the licensee did not comply with the section cited above as no evacuation chair is currently in place, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Licensee will obtain and install an evacuation chair and provide proof thereof to LPA before the plan of corrections due 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:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


LIC809 (FAS) - (06/04)
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