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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005608
Report Date: 05/10/2022
Date Signed: 05/10/2022 12:47:20 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/10/2022 12:47 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:TCT HOMES / PACIFICFACILITY NUMBER:
306005608
ADMINISTRATOR:ANTHONY AUFACILITY TYPE:
735
ADDRESS:9212 PACIFIC AVETELEPHONE:
(714) 827-2156
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 5DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Jim Fernandez, Assistant Administrator and Maxine Kniazeff, Assistant AdministratorTIME COMPLETED:
12:46 PM
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 On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required Annual Inspection. LPA Quiroz was greeted, COVID-19 screened and granted entry into the facility by House Manager (HM) Jim Fernandez. Facility is a Level 4I Facility. LPA Rosie Quiroz explained the nature of the visit. (HM) Jim Fernandez indicated all incoming visitors are COVID-19 screened prior to entering the facility. Assistant Administrator Maxine Kniazeff arrived shortly after. Adminsitrator Agustine Au has an Administrator's certificate with an expiration date of July 29, 2022.
On or about 11:38am, LPA Quiroz along with (HM) Fernandez began the tour of the inside and outside of the facility. There are five clients in care and there are no active COVID-19 cases in the facility. LPA Quiroz observed four of five clients walking around in living room and backyard area. (HM) Fernandez indicated "The clients enjoy walking for about 30 minutes after each meal." Client 1 arrived from Day program on or about 12:10pm. Five of five clients present at the facility during today's visit appeared to be clean and well taken care of. LPA Quiroz observed a COVID-19 check in station in the entry of the facility; LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility.
On or about 12:15pm, LPA Rosie Quiroz reviewed 5 of 5 clients records. All restrooms observed to have a supply of soap, appeared to be clean and water temperatures were recorded to be within 105.6 -111.4 degrees Fahrenheit. LPA Quiroz inspected client’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in office room area readily available for staff and clients. LPA Quiroz toured the outside of the facility and observed table and chairs in garage area for clients and visitor's enjoyment. (HM) Fernandez indicated "These current 5 clients prefer being indoors and don't hang out outside too much."

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SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: TCT HOMES / PACIFIC
FACILITY NUMBER: 306005608
VISIT DATE: 05/10/2022
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The facility has completed the LIC 808 Mitigation Plan. The LIC 808 plan was received by the Department on June 25, 2021. During today's visit, LPA Quiroz reviewed and approved LIC 808 Mitigation Plan dated
June 25 ,2021. LPA Quiroz was informed that "all clients and staff have had their COVID-19 vaccinations and Boosters and will be speaking to client's families regarding consent, and will schedule second boosters for those who consent." Facility is recording client's temperatures daily, two times per day.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

During today's visit, LPA Quiroz provided Consultation on Title 22 and COVID-19 Infection Control throughout today's visit.

This report was reviewed with (HM) Jim Fernandez and Assistant Administrator Maxine Kniazeff, and a copy of this report and LIC 811 Confidential Names were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC809 (FAS) - (06/04)
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