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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005705
Report Date: 05/16/2023
Date Signed: 05/16/2023 03:15:40 PM

Document Has Been Signed on 05/16/2023 03:15 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:EDWARD BOARD AND CARE HOMEFACILITY NUMBER:
306005705
ADMINISTRATOR:HERNANDEZ, MARISAFACILITY TYPE:
735
ADDRESS:117 EDWARD AVE.TELEPHONE:
(714) 290-3809
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 4CENSUS: 4DATE:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Esperanza RamirezTIME COMPLETED:
03:30 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad and Dwayne Mason Jr. for the purpose of conducting an Annual Inspection. LPAs met with Staff #1 (S1) Esperanza Ramirez and discussed the purpose of the inspection. Administrator (AD) Marisa Hernandez appeared via telephone.

LPAs reviewed Infection Control requirements. At about 12:30PM, LPAs and S1 conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and outdoor areas and observed the following: Structure. This is a one-story home. Facility is a 5-bedroom, 3-bathroom, one-story house. There is a back yard with a patio cover for the clients. LPAs observed 1 staff and 2 clients present at the facility. Client Bedrooms. The 4 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Lamps, chairs, linens, and storage for each client bedroom inspected. Staff Bedroom. LPAs observed the staff bedroom to be locked. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 114 and 117.6 F degrees. LPAs inspected all rooms in the facility except for the staff bedroom. Linens & Hygiene Supplies. New linens were observed in client bedrooms. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked in lockbox separate from toxins. Toxins: observed locked in a lockbox separate from knives. Medication observed locked in a lockbox. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 1:00 PM, LPAs reviewed 3 client files and 3 staff files, interviewed 2 clients and 1 staff, inspected medications for 1 out of 1 clients, and inspected client money and ledgers for 1 out of 1 clients.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
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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Document Has Been Signed on 05/16/2023 03:15 PM - It Cannot Be Edited


Created By: Sean Haddad On 05/16/2023 at 02:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: EDWARD BOARD AND CARE HOME
FACILITY NUMBER: 306005705

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility had a large bucket of standing water in the backyard with pests in it, which poses a potential health and safety risk to persons in care.
POC Due Date: 05/17/2023
Plan of Correction
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During the inspection, facility staff emptied out the bucket and disposed of the pests and LPAs confirmed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023


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: EDWARD BOARD AND CARE HOME
FACILITY NUMBER: 306005705
VISIT DATE: 05/16/2023
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During the inspection, LPAs and S1 observed the following in the backyard: a large bucket of standing water with pests in it. During the inspection, S1 emptied the bucket and disposed of the pests and LPAs confirmed. LPAs provided technical assistance regarding Infection Control Plan and Emergency Disaster Plan.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC809 (FAS) - (06/04)
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