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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005928
Report Date: 09/27/2024
Date Signed: 09/27/2024 01:21:55 PM


Document Has Been Signed on 09/27/2024 01:21 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 RO, 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: 6DATE:
09/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Gabriela GarciaTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility to conduct a Required - 1 year inspection. LPA was allowed entry into the home by Staff Alejandra Barrera and Sebastian Sanabria. Administrator (AD) Gabriela Garcia arrived shortly after. AD Garcia has a Certificate which expires on 05/29/2025.

There were 6 Residents present during today's visit. LPA, along with AD Garcia toured the physical plant. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each Resident comfortably. Bathrooms were checked, toilets/water faucets worked properly and shower was free of mold/mildew. Hot water temperature was within regulatory requirements. Bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Kitchen is clean and organized. Perishable and non-perishable food supply was checked and adequately stocked. LPA observed sharps and cleaning supplies locked in a kitchen cabinet and in the garage. Smoke detectors and carbon monoxide detector tested operational; Fire extinguisher was fully charged and mounted. No bodies of water were observed outside. Walkways around the home were clear of hazards. Exit gates are unlocked and self-latching. Backyard has a covered patio, patio furniture for outdoor activities and sufficient seating for Residents and visitors. Last Emergency/Fire Drill was conducted 3 weeks ago but not documented. LPA observed emergency supplies including food and water. LPA reviewed 6 Resident files and 2 staff files. Resident files contained required documentation such as health assessments and admission agreements. Staff files contained required documentation including fingerprint clearance and required training. Medication was observed to be in a centrally stored location and medication reviewed appeared to have been dispensed accurately.


Based on observations made during today’s visit, no deficiencies are being cited. This report was discussed with Administrator and a copy was sent to email on file.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 705-6004
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
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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