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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005644
Report Date: 08/19/2024
Date Signed: 08/19/2024 02:52:56 PM

Document Has Been Signed on 08/19/2024 02:52 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:NOUMEA CARE HOME IIIFACILITY NUMBER:
306005644
ADMINISTRATOR/
DIRECTOR:
BURGOS, CONSOLACION SFACILITY TYPE:
735
ADDRESS:6356 SHERMAN WAYTELEPHONE:
(714) 788-9165
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 4CENSUS: 1DATE:
08/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Karen SaturnoTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit before entering the facility. Staff called Assistant Administrator (AD) Karen Saturno who arrived and was present for the remainder of the visit. AD Saturno has a current administrator’s certificate that expires 11/7/26.

Around 12:00 noon LPA Haley began the tour of the facility with AD Saturno. All four clients were at their day program when the visit began. All client bedrooms were clean, well organized, and had all necessary requirements: night stand, chair, lamp and storage space. Client bathrooms were clean and organized. Hot water temperature was measured in the range of 107.6 – 108.6 degrees Fahrenheit.

The kitchen was clean and organized. All knives and sharp objects were locked under the stove. All burners on the stove were operational. The facility has a two-day supply of perishable food items and seven-day supply of nonperishable food items.

The garage was clean and well organized. Walkways are free of obstruction and tripping hazards. All hazardous chemicals are locked in a cabinet in the garage. There was also an additional food and water supply stored in the garage. A tread mill was observed across the washer and dryer.

The backyard was clean, organized, and walkways are free of obstruction. There’s a shaded patio and a table and chairs. There’s a side exit gate that’s self latching.

In the living room LPA Haley observed a locked filing cabinet, with staff and resident files, client P&I funds, and a first aid kit with all the required elements. On top of the locked medication cabinet are emergency bags for all the clients.

Continued on LIC809C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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 2
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: NOUMEA CARE HOME III
FACILITY NUMBER: 306005644
VISIT DATE: 08/19/2024
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During the visit, interviews were conducted with two staff, and one client. A medication and P&I audit was conducted for all four clients. Files were reviewed for all four clients and three staff.

No bodies of water observed. All smoke detectors tested and are operational. Three fully charged fire extinguishers were observed mounted on the wall in different areas of the facility.

No deficiencies are being cited during today’s visit. An exit interview conducted, and a copy of the report was provided.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC809 (FAS) - (06/04)
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