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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005929
Report Date: 04/15/2024
Date Signed: 04/15/2024 12:35:03 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/15/2024 12:35 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:MARTINO LOVING CARE, INC.FACILITY NUMBER:
306005929
ADMINISTRATOR/
DIRECTOR:		TRIEU, THANHFACILITY TYPE:
740
ADDRESS:1904 W. RANDOM DRIVETELEPHONE:
(714) 858-3535
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 0DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Thanh Trieu, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Ruth Martinez and Faith La and Licensing Program Manager (LPM) Armando Lucero is conducting this unannounced visit for the purpose of completing an annual required inspection. LPAs and LPM arrived at facility and rang the bell twice with no response. LPA called the phone number on file and asked whether the licensee could come to the facility to confirm the facility does not currently have any residents in care. LPA Martinez spoke to Thanh Trieu, Administrator and was informed he would meet us at the facility to let us conduct the inspection.

LPA accompanied by Administrator began the tour of the facility. LPAs and LPM did not observe any resident in care at the facility. Administrator informed LPA Martinez that there had never been any residents in care since the license was issued. Upon entry LPAs and LPM observed a gentleman occupant 1 indicating that they live at the premises until the facility admits a resident. Occupant 1 indicated that they have lived at premises over a year. Occupant 1 name did not reflect on facility association list. LPAs toured the kitchen and observed a fire extinguisher mounted on the wall with services date of January 06, 2021. First aid kit and book were observed to be mounted on the wall above the fire extinguisher. LPAs observed the Administrator Certificate to be expired with an expiration date of 6/30/2021. Administrator indicated they had a current certificate and will provide a copy to LPA by email. LPAs and LPM inspected the facility resident bedroom and observed the bedrooms to have all required components. LPA attempted to inspect the bedroom designated as the staff bedroom, but door was locked. Administrator informed LPAs and LPM that the bedroom is being rented to an individual. The occupant 2 of the bedroom arrived shortly after and allowed LPAs to inspect the bedroom. Occupant 2 indicated they had been living at premises for about 7 months. Occupant 2 name did not reflect on facility association list. Bathrooms were inspected and LPA Martinez measured the hot water temperature which measured 113.5 Fahrenheit degrees. Bathroom are equipped with required safety measures such as non-skid mats and grab bars. LPAs inspected residents’ bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage
Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MARTINO LOVING CARE, INC.
FACILITY NUMBER: 306005929
VISIT DATE: 04/15/2024
NARRATIVE
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space is provided for residents in their bedroom. Smoke and carbon monoxide detectors were tested and found to be operational. LPAs observed storage for linens in the bedroom hallway. LPA toured the outside of the facility and observed the garage to have an enclosed patio covered with a large blue tarp making it as an enclosed building. Administrator indicated that the owner of the property had filled for an ADU permit from the city of Anaheim to make the garage and add on for occupation purposes and LPAs and LPM were not allowed to inspect that portion of the premises. Administrator did not provide department staff with copies of permit for ADU, nor was the Licensing office notified of changes to premise. LPA Martinez observed a gentleman in the interior portion of the ADU unit. Occupant 3 names did not reflect on facility association list. As association list only has 2 individuals already identified on the inspection. Administrator indicated they did not know the occupants name, but indicated they had been living there for about a year. Administrator was unable to provide documentation for the permits or further information. LPAs toured the remainder portion of the backyard. Licensee will contact Community Care Licensing (CCL) to inform of when they are ready to accept new residents or if there are any changes with the license. LPA as a reminder provided annual fee dues information. In an effort to update the facility file, the Administrator is required to submit to the licensing agency a copy of the following: An updated Personnel Report (LIC 500) and Copy of Active Administrator Certificate (Certificate mounted on the wall expired June 30, 2021 for Thanh Trieu).

Based on this inspection, deficiencies were observed at this time in the areas evaluated per Title 22 Division 6 of the California Code of Regulations. See LIC 809-D for deficiencies. Civil Penalties were assessed on this date.

This report was reviewed with Administrator and a copy of this LIC809, LIC809-D report was provided and left at facility. Appeal rights reviewed, and a copy provided.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/15/2024 12:35 PM - It Cannot Be Edited


Created By: Ruth Martinez On 04/15/2024 at 10:48 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: MARTINO LOVING CARE, INC.
FACILITY NUMBER: 306005929

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2024
Section Cited
CCR
87755(a)

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87755 Inspection Authority of the Licensing Agency(a) Any duly authorized officer, employee or agent of the licensing agency may, upon proper identification and upon stating the purpose of his/her visit, enter and inspect the entire premises... This requirement was not met as evidenced by:
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In office meeting will be held with Licnesee to discuss the Department's Inspection Authority
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based on observation the garage has been converted to an ADU with occupants and LPAs were not allowed to inspect which poses an immediate health and safety risk to the persons in care. IMMEDIATE CIVIL PENALTY ASSESSED.
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Type A
04/16/2024
Section Cited
CCR87305(a)

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87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requiement is not met as evidenced by: based on observation it was observed the garage has been converted to
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Licensee to provide documentation for permits from the City of Anaheim by POC due date to LPA or the Department Regional Office.
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an ADU with occupants which poses an immediate health and safety risk to the persons in care. IMMEDIATE CIVIL PENALTY ASSESSED.
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Ruth Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/15/2024 12:35 PM - It Cannot Be Edited


Created By: Ruth Martinez On 04/15/2024 at 11:28 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: MARTINO LOVING CARE, INC.
FACILITY NUMBER: 306005929

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2024
Section Cited
CCR
87355(a)

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87355 Criminal Record Clearance (a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a ... This requirement was not met as evidence by: based on observation it was observed
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Licensee to obtained fingerprint clerance for all individuals at the premises.
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there is three individuals not listed on facility association and the Adminsitrator listed on association as pending clearance. which poses an immediate health and safety risk to the persons in care. CIVIL PENALTY ASSESSED.
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Type B
04/22/2024
Section Cited
CCR87203

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87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidence by: based on observation it was observed the Administrator did not ensure
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Administrator reach out to have the Fire Extinguishers serviced or purchase new Fire Extinguishers and submit proof to LPA via email by POC due date of 4/22/2024.
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the facility’s Fire Extinguisher was serviced annually (last serviced on 01/06/2021), which poses an immediate health and safety risk to the persons in care.
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Ruth Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024


LIC809 (FAS) - (06/04)
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