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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005885
Report Date: 01/05/2024
Date Signed: 01/05/2024 02:28:39 PM

Document Has Been Signed on 01/05/2024 02:28 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
ORANGE COUNTY ASC, 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: 6DATE:
01/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:House Manager - Saadieh Khalil TIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by House Manager Saadieh Khalil.

The facility is a one-story home with six client bedrooms, two client bathrooms, kitchen, dining room, living room, staff office, backyard and attached 2-car garage. LPA observed residents to be either away at day program or lounging in their bedroom. Facility appears clean and sanitary. All residents rooms had required elements, including bed, chair, closet space and ample lighting. Facility had extra linens for clients in the hallway closet. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured at 107.8 degrees Fahrenheit and 109.9 degrees Fahrenheit in the common bathrooms. LPA observed facility has emergency food and water supply. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in drawers in the kitchen. Cooking materials and chemicals are stored separately. Medication for each resident is kept locked in a cabinet in the dining room. The backyard has a shaded seating area. Exit gates are unlocked. LPA observed ramps and exit gates to be unobstructed. LPA reviewed three of the six client files, three personnel files, three clients' medication and the P&I. Files, Medication and P&I appear to be properly documented and stored. LPA interviewed one client. Facility goes on outtings, has board games, exercise equipment, electronics, and more for client use. Emergency contacts, Menu and Calendar are posted and available for review.

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

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2024
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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