<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005644
Report Date: 08/31/2021
Date Signed: 08/31/2021 09:53:56 AM

Document Has Been Signed on 08/31/2021 09:53 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:NOUMEA CARE HOME IIIFACILITY NUMBER:
306005644
ADMINISTRATOR:BURGOS, CONSOLACION SFACILITY TYPE:
735
ADDRESS:6356 SHERMAN WAYTELEPHONE:
(714) 788-9165
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 4CENSUS: 1DATE:
08/31/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:ConsolacionnBurgosTIME COMPLETED:
10:07 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA and staff toured the facility. Administrator Consolacion Burgos and Melba Santos arrived at 9:00am. Karen Saturno was also present. LPA observed all the bedrooms had the required furnishings. Both bathrooms were clean and operational. LPA observed medication locked in a cabinet. LPA observed the knives were kept locked in the kitchen. LPA inspected the first aid kit, First aid kit had all the required elements. The kitchen was clean and organized. LPA observed 2 day perishable and 7 day non-perishable food supply on hand. The fireplace in the living room is screened. LPA did not observe any hazards inside of the facility. LPA toured the backyard. The backyard has a covered patio and a seating area for clients. There is a ping pong table for the clients under the covered patio. The exit gate is operational. No bodies of water observed. LPA did not observe any obstacles or hazards in the back yard. LPA toured the garage. The garage is used for storage and for laundry. LPA observed cleaning supplies are kept locked in a cabinet. The garage is clean and organized. Smoke detectors tested operational. Facility has a mitigation plan that is pending review. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1