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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005885
Report Date: 01/10/2022
Date Signed: 01/10/2022 11:36:49 AM

Document Has Been Signed on 01/10/2022 11:36 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MON JOLI CHATEAUFACILITY NUMBER:
306005885
ADMINISTRATOR:SOONTHORNPONG, SUPARBFACILITY TYPE:
735
ADDRESS:1330 S FALCON STREETTELEPHONE:
(714) 774-7652
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: 4DATE:
01/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Administrator Suparb SoonthronpongTIME COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Jerome Haley and Joseph Alejandre conducted an unannounced visit for the purpose of conducting a required one year annual visit (mitigation annual). LPAs were greeted and granted entry by staff and explained the reason for the visit. Licensee Suparb Soonthornpong has a current administrator certificate expiring on 12/04/2022. Staff lead LPAs on a tour of the facility. There were four clients in care at the facility. LPA observed clients were talking to each other, smiling, laughing, and watching TV. One client was at day program and the another was out with family. There's a screening log book and thermometer for screening clients and visitors. LPAs began the tour checking client rooms and bathrooms. Client rooms have the necessary requirements, night stand, chair, lamp and dresser. Bathrooms were operational and clean. The water temperature in bathroom #1: 127.2 degrees Fahrenheit. Bathroom #2: 119.3 degrees Fahrenheit. LPAs toured the kitchen and there was a 2-day supply of perishable items and a 7-day supply of nonperishable items. There was a first aid kit equipped with all required items. The stove was clean and four of the five burners were operational. The facility has adequate PPE, consisting of gloves, N95 mask, surgical mask, and hand sanitizer. LPA observed extra linen, emergency food and water. LPAs toured the back yard and observed the exit gates that were self closing and self latching. While touring the backyard LPAs observed a pile of plant debris next to the exit gate on the side of the house by the front door. LPAs advised the licensee to removed the debris right away and the importance of keeping the back yard clean and free of clutter. LPA observed loose bricks in the back yard and LPAs advised staff the bricks need to be removed. While touring the back yard there were no bodies of water observed. LPA toured the garage area and it was clean and free of clutter. Smoke detectors were tested and are operational. LPAs consulted with licensee fire safety and the guardian website. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview conducted and a copy of the appeal rights were given to the Administrator at time of visit. A copy of the report was provided to the Administrator.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2022
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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Document Has Been Signed on 01/10/2022 11:36 AM - It Cannot Be Edited


Created By: Jerome Haley On 01/10/2022 at 10:39 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MON JOLI CHATEAU
FACILITY NUMBER: 306005885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Hot water temperture controls shall be maintained to automatically regulate temperture of hot water delivered to plummbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F and not more than 120 degrees F.
Deficient Practice Statement
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This requirements is not being met as evidenced by: LPA measured the hot water temperature in the bathroom #1 by the front entrance at 127 degrees F. This poses a potiential health and safety risk to clients in care.
POC Due Date: 01/14/2022
Plan of Correction
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LIcensee states that the hot water will be adjusted to ensure the temperature will be between 105 degrees F and 120 degrees F. Licensee stated staff will monitor the water temperature and keep track of it in a daily log to ensure the water is at the correct temperature. LIcensee to forward water temperature logs by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Luz Adams
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2022


LIC809 (FAS) - (06/04)
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