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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005714
Report Date: 07/15/2022
Date Signed: 07/15/2022 02:01:10 PM

Document Has Been Signed on 07/15/2022 02:01 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:SANTOS HOME CARE/PIERCEFACILITY NUMBER:
306005714
ADMINISTRATOR:SANTOS, MELBA M.FACILITY TYPE:
735
ADDRESS:7293 PIERCE CIRCLETELEPHONE:
(714) 699-1003
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 4CENSUS: 3DATE:
07/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator Melba Santos TIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management visit to Santos Home Care/Pierce. LPA was greeted, granted entry, and explained the reason for the visit. LPA Haley was screened and temperature checked before entering the facility.

The purpose of today's visit was to conduct a Case Management visit to discuss an Unusual Incident Report (LIC 624) that was sent to the Orange County Adult and Senior Care Regional Office July 12, 2022.

On today's visit LPA Haley discussed the incident report regarding Client 1 (C1) with Administrator Melba Santos.

No deficiencies are being cited during today's Case Management visit. An exit interview was conducted and a copy of this report was provided to Administrator Santos.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2022
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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