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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005935
Report Date: 06/18/2024
Date Signed: 06/18/2024 05:05:53 PM

Document Has Been Signed on 06/18/2024 05:05 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:PEER MENTAL WELLNESSFACILITY NUMBER:
306005935
ADMINISTRATOR/
DIRECTOR:		CARVER, MATHEW WILLIAMFACILITY TYPE:
775
ADDRESS:305 W. 4TH ST.TELEPHONE:
(714) 357-9988
CITY:SANTA ANASTATE: CAZIP CODE:
92701
CAPACITY: 30CENSUS: DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:55 PM
MET WITH:Lindsey LyonTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
NARRATIVE
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On June 18, 2024, at 1:55pm Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required annual inspection. LPA was greeted and granted entry by Lead Therapist (LT) Lindsey Lyon and stated the purpose of the visit. Administrator Mathew Carver stated over the phone he would not bet at the facility today.

LPA Kim accompanied by LT Lyon began the tour of the inside of the facility. Facility is a three story commercial building with a basement. Basement is used for a music studio for clients. There are two storage rooms, where one has a kitchen. No food supplies, sharps, or cleaning supplies are stored in the kitchen. There are two bathrooms located in the basement and two bathrooms located on the first floor with all having working wash basin, soap, paper towels, and toilet paper. On the first floor LPA observed 3 clinical office rooms and plenty of ample seating at the common area. The second floor has an office desk space in it. There is a dance/yoga studio on the third floor. LPA observe that the facility fire clearance is maintained in conformity with the State Fire Marshall regulatory standards. Smoke detectors and sprinkler systems are serviced annually by an outside vendor. There are Fire extinguishers that are charged and all serviced on June 12, 2024.

There are no bodies of water or obstruction at this location. Disinfectants cleaning solutions and poisons are inaccessible to clients and stored locked. The premises and furnishings are in good repair. There are no food preparation areas at this site. Clients provide their own lunches and/or go out for lunch. Facility provides snacks as needed. Clients were in a group session at the time of visit and are adequately supervised to meet their needs. Facility does not handle medication for clients and therefore does not have a location for medication storage. LPA observed all client’s have a medication lists on files.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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: PEER MENTAL WELLNESS
FACILITY NUMBER: 306005935
VISIT DATE: 06/18/2024
NARRATIVE
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First aid supplies are adequate, and LPA observed a first aid kit mounted in kitchenette on the first floor. During the inspection LPA reviewed three staff records, four client records. All employees have a criminal record clearance. During the inspection LPA conducted two staff interviews.

A deficiency was cited and a technical violation issued during this inspection visit as per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted and a copy of this report was provided to Lead Therapist Lindsey Lyon
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/18/2024 05:05 PM - It Cannot Be Edited


Created By: Edward Kim On 06/18/2024 at 04:46 PM
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: PEER MENTAL WELLNESS
FACILITY NUMBER: 306005935

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(a)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed the men's bathroom in the basement was not flushing. The basement bathrooms also had a dead cockroach in each toilet stall.This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Licensee states they will fix the basement men's bathroom toilet and clean up the men's and women's bathroom in the basement with a proof of corrected POC to CCLD via email to edward.kim@dss.ca.gov by June 28, 2024.
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
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