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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005779
Report Date: 05/09/2023
Date Signed: 05/09/2023 04:49:33 PM

Document Has Been Signed on 05/09/2023 04:49 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:PATRICIA HOMEFACILITY NUMBER:
306005779
ADMINISTRATOR:COLLANTES, DELIA B.FACILITY TYPE:
735
ADDRESS:10881 PATRICIA DRIVETELEPHONE:
(714) 624-9933
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 4CENSUS: 3DATE:
05/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Dante BenedictoTIME COMPLETED:
02:15 PM
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Licensing Program Analysts (LPA) Lydia Martinez made an unannounced visit to conduct a Required – 1 Year inspection. Upon arrival LPA was greeted by facility Staff Elmer Hahn and Teddy Santos and reason for visit was explained. There are currently 3 clients residing at the facility. One client and two staff were present during today's visit. Per staff, two clients are at Day Program. Assistant Administrator Dante Benedicto arrived shortly after.

LPA Martinez, along with Staff conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, living room, den, garage and observed the following:

Facility is a single story 3 bedroom, 2 bathroom home with an attached 2 car garage that is used for storage only. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. LPA observed a table and chairs under covered patio for clients and visitors. Client bedrooms were observed to be spacious and easily accommodate furnishings such as lamps, chair, dresser and a bed. Bathrooms were observed to be clean, have a supply of soap and paper towels. Hot water temperature was within regulatory requirements. Linen and hygiene supplies were stocked. Emergency Phone Numbers and Exit Plan were reviewed. Food prep area is clean and organized. Food supply meets the requirement of one (1) week supply of non-perishable and two (2) day supply of perishables. Smoke detectors and carbon monoxide detectors were found to be operational. Fire Extinguishers were charged and mounted and were last serviced on 06/15/2022. There is no record that drills have been conducted. Stove burners, microwave, washer, and dryer are operational. Chemicals and sharps are made inaccessible to the clients. Cleaning supplies are stored in garage. Medications are centrally stored in a locked filing cabinet kept in living room. Medications reviewed appear to have been dispensed accurately.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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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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: PATRICIA HOME
FACILITY NUMBER: 306005779
VISIT DATE: 05/09/2023
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First-Aid Kit had all the required elements and Activity Supplies were observed and available. There is a working land line at the facility.

LPA reviewed three client files and one staff files. LPA interviewed 1 staff. The clients P&I records were reviewed, LPA observed that an individual log is maintained for each client. All monies are accounted for and logs were kept to date.

Indoor and outside passageways are free of obstruction.

In order to update CCL file, please provide the following updated documents to CCL by 05/26/2023: 1.) Designation of Administrative Responsibility (LIC308) 2.) Personnel Report (LIC500); 3.) Emergency Disaster Plan (LIC610D); 4.) Surety Bond; and 5.) Administrator certificate.



Based on observations made during today's visit in the areas reviewed, no deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations. Copy of this report will be sent to email on file.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC809 (FAS) - (06/04)
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