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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005608
Report Date: 06/23/2023
Date Signed: 06/23/2023 04:03:08 PM

Document Has Been Signed on 06/23/2023 04:03 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: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:
06/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Maxine KniazeffTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Lydia Martinez made an announced visit to the facility to conduct a Required - 1 Year inspection. LPA was greeted and granted entry by Staff Felipe and Helen Nelmida and reason for visit was shared. Administrator Augustine Au and Assistant Administrator (AD) Maxine Kniazeff arrived shortly after. AD Kniazeff has a current Administrator's Certificate that expires on 07/28/2024. Two staff and one client were present during today's visit. Four clients are at Program.

The facility is a one story home with 6 Bedrooms, 3 Bathrooms, Kitchen, Dining Room, Living Room, Office and 2 car garage that is used for storage.

LPA Martinez, along with Staff Helen toured the inside and outside of facility. LPA observed all required postings at the entrance of the facility. There is no Live-in staff. The kitchen was clean and well organized. All knives and sharp objects are inaccessible to clients. The facility has a two day supply of perishable food items, a seven day supply of non perishable food items, and a variety of fruit available. All hazardous chemicals were locked in the garage. Fire Extinguisher was mounted and charged, last serviced on 08/25/2022. The garage was clean, organized and walkways were free of tripping hazards. LPA observed a variety of food items and an emergency supply of water and food. LPA observed emergency bags and emergency kits prepared and ready to go for each client in care. Client bedrooms were clean, well organized, and equipped with all the necessary requirements: night stand, chair, lamp and storage space. Bathrooms were clean and sanitary. Hot water temperature in client bathrooms was within regulatory requirements. The backyard area was clean, organized free of clutter and walkways were free of tripping hazards. There is a shed in the backyard that is used for storage. Side exit gates are self closing and self latching. Ample supply of linen and hygiene supplies were observed to meet the needs of all clients in care. Emergency Phone Numbers and Exit Plan was in place. Fire drills are conducted monthly and LPA verified last Fire Drill was conducted on 06/05/2023. Medications are centrally stored in a locked cabinet in the office. Medications reviewed appear to have been dispensed accurately.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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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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: 06/23/2023
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First-Aid Kit had all the required elements and Activity Supplies were observed and available. There is a working land line at the facility. The LIC610D, Emergency Disaster Plan is posted.

LPA reviewed five client files and two staff files. LPA interviewed two staff. The clients P&I records were reviewed, LPA observed that an individual log is maintained for each client.

Based on observations made, no deficiencies were observed at this time in the areas evaluated. Copy of this report will be sent to email on file.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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