306005714-10-21-2022-22-AS-JHAY-CKESZ4-20221021141830

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005714
Report Date: 10/21/2022
Date Signed: 10/21/2022 02:18:35 PM

Document Has Been Signed on 10/21/2022 02:18 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/PIERCE		FACILITY NUMBER:	306005714
ADMINISTRATOR:	SANTOS, MELBA M.		FACILITY TYPE:	735
ADDRESS:	7293 PIERCE CIRCLE		TELEPHONE:	(714) 699-1003
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 4		CENSUS: 3	DATE:	10/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Melba Santos		TIME COMPLETED:	02:25 PM

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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Administrator (AD) Melba Santos was present for the visit and she has a current Administrators certificate that expires 06/30/24.

At 1:08 PM LPA Haley began the tour of the facility with AD Santos. There were three clients present for the visit. All client bedrooms were clean, well organized, and had all necessary requirements: night stand, chair, lamp and storage space. Both client bathrooms were clean and organized. Hot water temperature was measured at 110.8 degrees Fahrenheit in client bathroom #1 and 116.7 degrees Fahrenheit in client bathroom #2. In a hallway locked hallway closet LPA observed plenty of clean linen and hygiene supplies. In the hallway closet near the living room LPA observed a well stocked supply of nonperishable food items.

In the living room, LPA observed a locked file cabinet with client files, staff files, and on top of the file cabinet is a lock box for families to write concerns or grievances if needed. A screening station with a temperature thermometer, screening log book, hand sanitizer and face mask was observed at the entrance of the living room near the front door.

The kitchen was clean and well organized. All hazardous chemicals, knives and sharp objects were locked under the sink. There's a locked cabinet used to store client medication, and multiple first aid kits with all required elements was observed in the locked medication cabinet. 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. On the side of the refrigerator, LPA observed a closet full of additional nonperishable food items. A fully charged fire extinguisher was mounted near the sink.

Continued on LIC809C Dated 10.21.22

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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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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: SANTOS HOME CARE/PIERCE	FACILITY NUMBER: 306005714
	VISIT DATE: 10/21/2022

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The backyard was clean, organized, and free of clutter. LPA observed a shaded area with a table and chairs. There is a pool surrounded by an alarmed and secured gate that meets regulation requirements. The side exit gate was self closing and self latching. A locked storage shed used for storing tools was observed.

The garage was clean and well organized. The garage is used as a recreation area for the clients with plenty of games and activities for them to enjoy. LPA observed a mounted TV, board games, a treadmill, a stationary bike, and a basketball station. A screening station with a temperature thermometer, mask, and sanitizer was observed. LPA observed awell organized section of the garage with emergency supplies ready to go. Emergency bags, emergency PPE, emergency food and water, and emergency bags of clothing was observed. There is a locked cabinet with plenty of PPE and cleaning supplies. LPA observed Lysol, N95 mask, surgical mask, gloves, alcohol wipes, alcohol, bleach, and COVID test kits. Between the garage and kitchen LPA observed a laundry room with a washer and dryer. in the laundry room there's a locked cabinet used to store laundry detergent.

All smoke detectors were tested and are operational. No deficiencies are being cited during todays visit. An exit interview conducted and a copy of the report was provided to Administrator Melba Santos.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC809 (FAS) - (06/04)

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