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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005992
Report Date: 07/21/2023
Date Signed: 07/21/2023 11:28:45 AM

Document Has Been Signed on 07/21/2023 11:28 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:
07/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Nicholas RomoTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Administrator (AD) Nicholas Romo and discussed the purpose of the inspection.

During the inspection LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a one-story home with three client bedrooms, three bathrooms, one staff bedroom, and a second staff bedroom located in the loft space over the two-car garage. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. The back yard has a shaded sitting area. LPA observed two staff and thre clients present. Bathroom faucets and toilets were operational. Water temperature tested at 111.3 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted at the entrance of the facility. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Facility appliances were inspected. Three out of five stove burners were observed to be inoperable; a deficiency was cited on this date. Sharps were observed to be inaccessible to clients. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are locked and inaccessible to clients as well. Medication cabinet was observed to be locked and lock is operational. The first aid kit has all the required elements. LPA reviewed three out of three client files and three staff files. LPA interviewed three clients and two staff.

Based on the observations made during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2023
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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Document Has Been Signed on 07/21/2023 11:28 AM - It Cannot Be Edited


Created By: Claudia Gutierrez On 07/21/2023 at 10:37 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: ROMO HOME, THE
FACILITY NUMBER: 306005992

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
The facility shall be clean, safe, sanitary, and in good repair at all times for the safety and well-being of cleints, employees and visitors

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and AD interview, the licensee did not comply with the section cited above as three out of five stove burners are inoperable, which poses a potential safety risk to persons in care.
POC Due Date: 08/21/2023
Plan of Correction
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AD stated they would repair stove and provide LPA with video proof of all five burners igniting as designed via email by POC date. AD also stated they would monitor stove and all appliances to ensure they are operable at all times.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023


LIC809 (FAS) - (06/04)
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