306006022-8-15-2024-22-AS-MTEA-D86VCX-20240815161952

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006022
Report Date: 08/15/2024
Date Signed: 08/15/2024 04:20:14 PM

Document Has Been Signed on 08/15/2024 04:20 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:	CALIFORNIA HOME CARE		FACILITY NUMBER:	306006022
ADMINISTRATOR/ DIRECTOR:	MALLARI, ANNA		FACILITY TYPE:	735
ADDRESS:	15672 CALIFORNIA STREET		TELEPHONE:	(657) 600-8434
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY: 4		CENSUS: 4	DATE:	08/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:34 PM
MET WITH:	Anna Mallari		TIME VISIT/ INSPECTION COMPLETED:	04:35 PM

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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by Direct Service Personnel (DSP) Marissa Notarte. The Administrator (AD), Anna Mallari arrived shortly to assist with the visit. The facility is licensed for 4 non-ambulatory clients. Currently there are 4 clients living here during today's visit.

At 1:25 PM, LPA Tea reviewed four client files and three staff files. Client files and staff files contained all required documentation. The administrator certificate expires on August 31, 2024, however administrator has complied with all course work and is pending renewal at this time.

LPA Tea along with the DSP Notarte toured the facility at 2:27 PM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a one story home with four client bedrooms, one staff room, and two bathrooms. The facility has a kitchen, dining room, and living room with an attached garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured between 114.2 F degrees and 115.3 F degrees. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked underneath the kitchen sink. LPA also observed toxin substances to be secured and locked and inaccessible to clients in a storage closet in the garage.

Continuation of annual report on LIC809C

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CALIFORNIA HOME CARE	FACILITY NUMBER: 306006022
	VISIT DATE: 08/15/2024

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The fire extinguisher by the kitchen area is fully charged in the facility. The facility’s last fire drill was conducted on July 13, 2024. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade. LPA observed emergency supplies, food, and water in a storage closet by the front entryway. LPA Tea observed clients just returning from an outing to Downtown Disneyland for a client’s birthday. The staff provide activities based on client’s personal preference such as puzzles, board games, exercises in the backyard and walks around the neighborhood. Every so often the staff would take the clients on outings.

At 2:48 PM LPA reviewed medication storage and administration. Medications are stored in locked closet by the front entryway. Medications are being administered per physician order. P&I Funds were checked and meet department standards. LPA interviewed clients regarding their quality of care and spoke to staff present regarding care provided.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with AD Anna Mallari and a copy of this report LIC809, 809-C, LIC858, LIC859, and LIC9102TV was read and provided to the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

LIC809 (FAS) - (06/04)

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