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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005992
Report Date: 07/08/2024
Date Signed: 07/08/2024 03:03:52 PM

Document Has Been Signed on 07/08/2024 03:03 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:ROMO HOME, THEFACILITY NUMBER:
306005992
ADMINISTRATOR/
DIRECTOR:		ROMO, NICHOLAS ANTHONYFACILITY TYPE:
735
ADDRESS:7621 SEINE DRIVETELEPHONE:
(714) 841-8208
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: 3CENSUS: 3DATE:
07/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Administrator, Nicholas RomoTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 7/8/2024, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by staff and granted entry after stating the purpose of the visit. Administrator (AD) Nicholas Romo was present to assist with the facility inspection on today's date.

The facility is a licensed Adult Residential Facility serving Developmentally Disabled Clients. Facility is licensed for three (3) ambulatory clients, there are two client's present during today’s visit.

This is a single story with a two car garage facility. The facility has five (5) bedrooms (three client rooms, one staff office and a second staff bedroom located in the loft space over the two car garage. Facility has two full bathrooms.

At around 9:30 AM, LPA conducted a tour of the physical plant accompanied by Administrator Romo, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 111.9 degrees F. A comfortable temperature of 73 degrees F. was maintained in the facility.



LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, toxins, medications, and sharps objects were stored and not accessible to residents. The kitchen was inspected, facility has operational fridge and stove. LPA observed facility has sufficient two day supply of perishable and seven day supply of non-perishable food was maintained adequately. Facility has two fire extinguishers which were mounted and fully charged. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance.

CONTINUED ON 809C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: ROMO HOME, THE
FACILITY NUMBER: 306005992
VISIT DATE: 07/08/2024
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During the visit, LPA observed facility had emergency food and water supply. LPA observed emergency lighting. LPA observed the facility's infection control practices. LPA observed the facility has supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working land line phone was operational. The last fire drill was conducted on June 14, 2024. LPA observed facility had tested operational smoke and carbon monoxide detectors in bedrooms and common areas. The facility has current liability insurance on file effective 6/25/2024 - 6/25/2025. Facility has Surety Bond on file effective 3/10/2024- 3/10/2025. Facility has tablet devices with internet access available for all clients. The facility is current on Community Care Licensing annual dues.

A review of three clients (C1-C3) service files and two staff (S1-S2) personnel files revealed to be complete. The facility has the current administrator's certification on file for Nicholas Romo # 6059466735 - Expiration date 04/29/2025.

No deficiencies during this inspection visit.

An exit interview was conducted with Administrator Nicholas Romo, and a copy of the report was provided.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024
LIC809 (FAS) - (06/04)
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