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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006038
Report Date: 12/28/2023
Date Signed: 12/28/2023 03:06:58 PM

Document Has Been Signed on 12/28/2023 03:06 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SANTA TERESA CARE VILLAFACILITY NUMBER:
306006038
ADMINISTRATOR:ALIPIO, MARK JOHN MFACILITY TYPE:
735
ADDRESS:12782 SPRING STTELEPHONE:
(714) 622-5979
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY: 4CENSUS: 4DATE:
12/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Samuel Jones - House ManagerTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by House Manager (HM) Samuel Jones. Administrator (AD) Divina Alipio arrived approximately fifteen minutes after the LPA's arrival.

The facility is a one-story home with four client bedrooms, two client bathrooms, kitchen, dining room, living
room, den, backyard and attached 2-car garage. LPA observed residents to be away at Day Program or exercising/relaxing at the facility. The facility appears clean and sanitary. All client rooms had required elements, including bed, chair, closet space and ample lighting. Facility had extra linens for clients in the hallway closet. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured 109.2 degrees Fahrenheit in the common bathroom and 108.2 degrees Fahrenheit in the bathroom in one of the client rooms. LPA observed facility has emergency food and water supply. LPA observed knives to be locked under the kitchen sink separately from chemicals. LPA observed other hazardous materials like chemicals and cleaners to be locked in a closet. Medication for each resident is kept locked in a cabinet in the den. The backyard has a shaded seating area. Exit gates are unlocked and self latching. LPA observed exit gates to be unobstructed. LPA reviewed four of the four client files. LPA also reviewed three personnel files. LPA also reviewed P&I and Medicaiton for all clients. LPA noted one client does not receive P&I. The facility also has holiday decorations, various games and clients also get to participate in gardening amongst other activities.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was
provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023
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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