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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005928
Report Date: 07/19/2022
Date Signed: 07/20/2022 08:15:55 AM


Document Has Been Signed on 07/20/2022 08:15 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:MOM'S RETREAT BOARD AND CARE HOMEFACILITY NUMBER:
306005928
ADMINISTRATOR:GILROY, DENISEFACILITY TYPE:
740
ADDRESS:607 S. PINE DRIVETELEPHONE:
(714) 829-6024
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:6CENSUS: 4DATE:
07/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:33 PM
MET WITH:Administrator Gabby GarciaTIME COMPLETED:
02:21 PM
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Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Administrator Gabby Garcia and explained the reason for the visit.
LPA Frank toured the facility. There are 4 residents residing in the facility and no active COVID-19 cases. LPA observed 4 residents on site appeared clean and well taken care of. LPA observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Resident bedrooms appeared clean and sanitary and had all confirmed food supply: 2 day supply of perishables and 7 day supply of non-perishable food is available for the number of residents present. Hygiene supplies and supply of linen were observed in quantities for the number of residents in care. LPA observed locked areas for toxins and hazardous items. Medication were observed locked in cabinet. LPA observed the facility to be clean and in good repair.
LPA Frank reviewed : 1.) Emergency Disaster Plan (LIC610E); 2 ) LIC 9020A Client Roster; LIC 808) Mitigation Plan and 3) Current Liability Insurance, Designation of Administrative Responsibility (LIC308) and Personnel Report (LIC500).
Based on the observations made during today’s visit, no deficiencies are being cited in area inspected. This report was discussed with the facility representative and a copy was provided.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Shobhana FrankTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
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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