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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006022
Report Date: 06/21/2022
Date Signed: 06/21/2022 03:52:38 PM

Document Has Been Signed on 06/21/2022 03:52 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:CALIFORNIA HOME CAREFACILITY NUMBER:
306006022
ADMINISTRATOR:MALLARI, ANNAFACILITY TYPE:
735
ADDRESS:15672 CALIFORNIA STREETTELEPHONE:
(657) 600-8434
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 4CENSUS: 2DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Marisa Notarte- Caregiver TIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into facility by Caregiver Marisa Notarte and explained the reason for the visit.

At 3:05 PM, LPA toured facility with Caregiver Marisa Notarte. Facility has 2 clients present during today’s visit. Facility is a 4 bedroom, 2 bathroom, single story home with an attached garage. LPA observed a screening and sanitizing station at entrance of the facility. LPA observed clients relaxing in the facility or in their respective rooms. Facility appears clean and sanitary. All clients rooms had required elements, including bed, chair, closet space and ample lighting. Restrooms are stocked with soap and paper towels and have hand washing postings. Facility has 2 refrigerators with ample food supply. LPA observed facility has emergency food and water supply. Facility has a secured location for client files. LPA observed an unlocked medication closet. LPA toured the outside grounds and observed outside visitation area. Exit gate are locked and self latching. Facility has a plan for covid testing clients and staff as needed as well as a plan for isolation. LPA observed a 4 weeks supply of PPE. LPA reviewed all client files and all contained required documentation including updated emergency information. All staff and clients are fully vaccinated for Covid 19.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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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Document Has Been Signed on 06/21/2022 03:52 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 06/21/2022 at 03:41 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: CALIFORNIA HOME CARE
FACILITY NUMBER: 306006022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
(k) The following requirements shall apply to medications which are centrally stored:
(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPA observed an unsecured medication closet which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/22/2022
Plan of Correction
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Corrected during visit.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022


LIC809 (FAS) - (06/04)
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