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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006021
Report Date: 08/19/2022
Date Signed: 08/19/2022 03:38:00 PM

Document Has Been Signed on 08/19/2022 03:38 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:SIANI ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
306006021
ADMINISTRATOR:ESPANA, SHARONDAFACILITY TYPE:
735
ADDRESS:4591 LARKSPUR CIRCLETELEPHONE:
(909) 767-7030
CITY:ANAHEIMSTATE: CAZIP CODE:
92807
CAPACITY: 4CENSUS: 2DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Sharonda Espana, Venessa ClayTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection in this facility. LPA met with staff Venessa Clay and Administrator/Licensee Sharonda Espana and stated the purpose of this visit.

The facility is a single level structure and licensed for four ambulatory. This facility offers a Level IV-C service.

At about 1:30 PM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed one client in care and one staff member on duty. LPA toured the interior and exterior portions of the facility. There were four private client rooms two rooms were vacant. Client rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide alarms and were tested to be operational. Bathroom (1) was observed to be in good repair and hot water was measured at 131.0 degrees Fahrenheit. Bathroom (2) was observed to be in good repair and provided and hot water was measured at 125.7 degrees Fahrenheit. Administrator was made aware of water temperature regulation. Facility met the minimum two-day supply of perishable and seven day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to clients in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. LPA did notice in the front entrance by the walking path there was some loose bricks. Administrator stated they have let the property manager know and they have not gotten back to her with a fix date. Facility offers a 2-car garage mainly used for storage with a car and an operational washer and dryer. Medications and toxins where locked and kept away from clients. Kitchen was in good repair with knifes kept locked. LPA Tapia reviewed the COVID 19 mitigation plan and the emergency disaster plan of the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SIANI ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 306006021
VISIT DATE: 08/19/2022
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LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, one deficiency was noted in areas observed. No citation and one advisory was issued.

LPA Tapia conducted an exit interview with Administrator/Licensee Sharonda Espana and a copy of this report was explained and left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/19/2022 03:38 PM - It Cannot Be Edited


Created By: Edward Tapia On 08/19/2022 at 03:13 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: SIANI ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 306006021

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)


This requirement is not met as evidenced by:

Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two out of two restrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2022
Plan of Correction
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Administrator will adjust the water temperature to meet regulation requirements.
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:Sheila Santos
LICENSING EVALUATOR NAME:Edward Tapia
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022


LIC809 (FAS) - (06/04)
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