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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005714
Report Date: 11/13/2023
Date Signed: 11/13/2023 10:30:32 AM

Document Has Been Signed on 11/13/2023 10:30 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
ORANGE COUNTY ASC, 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: DATE:
11/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:TIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived for an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by DSP Junne Collado and Administrator Melba Santos.

The facility is a one-story home with four resident bedrooms, two resident bathrooms, kitchen, dining room, living room, laundry room, back yard with pool and attached two-car garage. LPA noted that two residents were away at day program during visit. Facility appears clean and sanitary. All residents rooms had required elements, including bed, chair, closet space and ample lighting. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured at 107.4 degrees Fahrenheit in the bathroom in bedroom 1 and 105.4 degrees Fahrenheit in the bathroom accessible from the hallway. A supply of extra linen and hygiene supplies are stored in a closet in the hallway. An emergency food supply is stored in the hallway closet. Fire extinguishers were observed to be fully charged and were last serviced on 03/04/2023 according to the service tags. Dual Smoke/Carbon Monoxide detectors tested operational. Garage has been converted into an activity/lounge area for residents. Facility has a supply of extra linen and hygiene supplies stored in the hallway closet. Activity materials include, an arcade basketball game, treadmill/other exercise equipment and a piano. LPA observed facility has emergency food and water supply stored in the garage. Facility has a pool that is fenced all the way around and has two latched gates on either side. Both exit gates in the backyard are operational and accessible. Medication, first aid kit and facility files are stored in locked cabinets in the dining area/kitchen. LPA reviewed all four resident files. LPA reviewed P&I with administrator. P&I was money reviewed, accounted for and appeared to be documented properly. LPA interviewed the only resident available for interview.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was provided to the administrator.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2023
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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