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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005823
Report Date: 07/31/2023
Date Signed: 07/31/2023 01:20:26 PM

Document Has Been Signed on 07/31/2023 01:20 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:TRUE REFUGEFACILITY NUMBER:
306005823
ADMINISTRATOR:RILLERA, MICHAEL P.FACILITY TYPE:
735
ADDRESS:4331 FIRESIDE CIR.TELEPHONE:
(949) 653-7562
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY: 5CENSUS: 3DATE:
07/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Michael Rillera, Armando FloresTIME COMPLETED:
01:35 PM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Licensee (LE) Michael Rillera and discussed the purpose of the inspection. Administrator (AD) Armando Flores arrived during the inspection.
LPA reviewed Infection Control requirements. At about 10:30AM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure: facility is a 4-bedroom, 3-bathroom, one-story house with an attached garage that is being used for activities. There is a back yard with a patio cover for the clients. LPA observed 1 staff, other than LE and AD, and 1 client present at the facility. Client Bedrooms: the 4 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 110 degrees F in the south hallway bathroom, 112 in the master bedroom bathroom, and 117 in the north hallway bathroom. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA 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: observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen drawer. Toxins: observed locked in the cleaning closet and in the garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees are paid. At about 11:30AM, LPA reviewed 3 client files and 4 staff files, interviewed 1 client and 1 staff, inspected medications for 3 clients, and inspected client money and ledgers for 3 clients.
There were no deficiencies observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2023
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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