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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005836
Report Date: 10/19/2022
Date Signed: 10/19/2022 04:26:19 PM


Document Has Been Signed on 10/19/2022 04:26 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:CASA DOLCE HOMEFACILITY NUMBER:
306005836
ADMINISTRATOR:EMIGH, JEANINEFACILITY TYPE:
740
ADDRESS:1601 SKYLINE DRIVETELEPHONE:
(714) 213-8423
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:6CENSUS: 4DATE:
10/19/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Yvette CabreraTIME COMPLETED:
04:40 PM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of a health and safety check. LPA met with Staff #1 (S1) Yvette Cabrera and explained the purpose of the inspection. Administrator (AD) Jeanine Emigh appeared via telephone.

During the inspection, LPA and S1 toured the facility. LPA conducted health and safety checks on the 4 residents and confirmed they were doing well and LPA observed no health and safety issues. LPA observed the facility to be clean and organized, and found no health and safety issues. 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. LPA observed S1 to be the only staff present. LPA requested and reviewed copies of the resident files for the 4 residents.

LPA interviewed AD who stated that the facility has gaps in staff coverage due to call-outs in the next few days, but that AD is working with a staffing agency to cover those gaps, AD is working on hiring permanent staff to cover those gaps, and AD may be able to cover those gaps themselves. LPA advised AD to continue efforts to ensure the facility is properly staffed, to notify the Long Term Care Ombudsman of the situation, to keep LPA apprised of the situation, and to discuss with LPA alternative possibilities for the residents and facility should the staffing issues continue.

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.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
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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