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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005992
Report Date: 07/05/2022
Date Signed: 07/05/2022 10:39:40 AM

Document Has Been Signed on 07/05/2022 10:39 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:ROMO HOME, THEFACILITY NUMBER:
306005992
ADMINISTRATOR:ROMO, NICHOLAS ANTHONYFACILITY TYPE:
735
ADDRESS:7621 SEINE DRIVETELEPHONE:
(714) 841-8208
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: 3CENSUS: 3DATE:
07/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Administrator/Licensee, Nicholas RomoTIME COMPLETED:
10:50 AM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and was granted entry into the facility by Administrator. LPA Tirre met with Administrator/Licensee Nicholas Romo and explained the reason for the visit.

During the visit LPA toured the facility with Administrator. Facility is a 5 bedroom ( 3 client bedrooms and 2 live in staff rooms) and 3 bathroom single story home. There are 3 Clients in care. LPA observed proper covid signage at front entrance of facility as well as sanitization and temperature check station. Facility has required Department postings posted. Administrator Certificate posted with observed expiration date 4/29/2023. LPA toured all clients rooms, all rooms where within regulations. All restrooms observed contained working wash basin, soap toilet paper and towels. Restrooms had hand washing signs posted. LPA observed Clients relaxing in living room watching TV and relaxing outside.

Facility has PPE supplies and Administrator was explained the importance of having 30 day supply on hand. LPA observed emergency food and water supply. Facility has fridge with ample food supply. Facility has required Emergency Disaster Plan posted. Facility has a secured location for Client medication and files. Facility has a secured location for toxins. Facility has 30 days supply of medications for clients. LPA reviewed Clients files during visit. 3 of 3 clients files were observed. Clients emergency contact information and Physicians reports are current. Facility has centrally wired operational smoke detectors and 2 fire extinguishers fully charged and mounted. Facility has designated area for visitors.

No deficiencies observed during visit. An exit interview was conducted with Administrator and copy of report was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2022
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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