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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005983
Report Date: 06/07/2022
Date Signed: 06/07/2022 03:24:28 PM


Document Has Been Signed on 06/07/2022 03:24 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:LA PALMA HOMECAREFACILITY NUMBER:
306005983
ADMINISTRATOR:BULLER, KATHRINAFACILITY TYPE:
740
ADDRESS:1418 W LA PALMA AVETELEPHONE:
(714) 833-5911
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:6CENSUS: 4DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:Kathrina BullerTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted and granted entry by staff. LPA met with Administrator Kathrina Buller. LPA and Administrator toured the facility. Facility has 5 bedrooms and 2 bathrooms, office, living room, dining room, kitchen and a 2 car detached garage. LPA observed the fireplace in the living room is screened. Smoke detectors tested operational. LPA observed all 5 resident bedrooms had the required furnishings and were clean and organized. LPA observed all bathrooms were clean and operational. LPA observed a 2 day perishable and 7 day non-perishable food supply on hand The kitchen is clean and organized. Cleaning supplies and knives are kept locked under the sink. LPA observed in the kitchen. medications are kept locked in a kitchen cabinet. No obstacles or hazards observed inside of the facility. LPA and Administrator toured the garage. The garage is detached and kept locked. The garage is used for storage and extra food. The side of the house has a small yard with a sitting area for residents. The exit gates on each side of the house are operational. The back area of the facility is the driveway area with access to the garage and is paved. This area is inaccessible to residents. No bodies of water observed outside the facility. No obstacles or hazards observed outside of the facility. No deficiencies observed during the visit. No deficiencies are being cited. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
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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