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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005634
Report Date: 08/23/2021
Date Signed: 08/24/2021 07:46:18 AM

Document Has Been Signed on 08/24/2021 07:46 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:UNIQUE CARE 4FACILITY NUMBER:
306005634
ADMINISTRATOR:NASSIF, JOSEPHFACILITY TYPE:
735
ADDRESS:1418 BAKER AVETELEPHONE:
(714) 853-1094
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 6CENSUS: 6DATE:
08/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Maria JimenezTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced visit for the purpose of conducting a Required - 1 Year evaluation. LPA was greeted and granted entry into the facility by Caregivers Felix Priego and Maria Elena Gallegos. Administrator Maria JImenez arrived shortly after.

LPA toured the facility with Caregivers Felix and Maria Elena.. There are 6 client in care. LPA observed signs to be posted at front entrance of facility on COVID-19 precautions, as well as a sign in sheet, sanitization and temperature check station. Facility has required Department postings. LPA observed copy of Administrators Certificate which expires on 11/22/2022. LPA toured all client rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper and paper towels. Restrooms had proper hand washing signs posted. Client's were observed in their room watching TV and/or relaxing. Facility has operating smoke and carbon monoxide detectors. Facility has Fire Extinguishers which are fully charged. Facility has ample supply of PPE. Facility has a refrigerator in kitchen with ample food supply. LPA observed facility has emergency food and water supply. Facility has required Emergency Disaster Plan posted, a secured location for client's medication and files. Facility has 30 days supply of medications for clients. Clients emergency contact information and Physicians reports are current. Visitor's visit in outside covered patio.

No deficiencies noted during todays visit. An exit interview was conducted with Administrators and a copy of report were left at facility.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2021
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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