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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006065
Report Date: 11/10/2021
Date Signed: 11/12/2021 07:52:52 AM

Document Has Been Signed on 11/12/2021 07:52 AM - 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:ST. MARCOS CARE HOMEFACILITY NUMBER:
306006065
ADMINISTRATOR:PESIGAN, FELIXFACILITY TYPE:
735
ADDRESS:6353 SAN MARCOS WAYTELEPHONE:
(714) 723-0341
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 4CENSUS: 4DATE:
11/10/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Melody Bungcayao & Felix PesiganTIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Lydia Martinez conducted a visit to the facility to conduct an announced Pre-Licensing evaluation. Upon arrival, LPA met with Applicant Melody Bungcayao and Administrator Felix Pesigan. An initial application to operate an Adult Residential Facility (ARF) was submitted to the Central Applications Unit (CAU) for a capacity of 4 Ambulatory clients. Facility is an existing facility and 4 clients were present. The Orange County Fire Authority Planning and Development Services conducted a Fire Safety Inspection on 10/15/2021 and granted a Fire Clearance. A tour of the physical plant was conducted inside and out at approximately 3:40 PM with Applicant and Administrator and the following was observed:
Structure:
Facility is a one story house with 6 bedrooms and 3 bathrooms. Bedroom #4 and #6 are designated as staff bedrooms. There is a living room/dining area, office and kitchen.
Signal System:
Central air/heating system installed with a central panel to control entire house.
Bedrooms Clients:
The client bedrooms accommodate clients' furnishings and meet Title 22 regulation at this time.
Bathrooms:
The 3 bathrooms have a working toilet, wash basin, and shower. Grab bars and non-slip mats were present.
Linens and Hygiene Supplies
Adequate supply of linens and hygiene items were observed
Ombudsman Poster, Personal Rights and See Something Say Something Poster
Ombudsman poster will be obtained once licensed, Personal Rights was posted and See Something Say Something will be printed and posted.
Food Service:
Adequate supply of 7-day non-perishable and 2 day perishables will be stored in the kitchen and pantry and will include fruits and vegetables.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2021
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ST. MARCOS CARE HOME
FACILITY NUMBER: 306006065
VISIT DATE: 11/10/2021
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Smoke and Carbon Monoxide Detectors:
Smoke detectors and carbon monoxide systems were observed working at the time of this visit
Fire Extinguishers:
The fire extinguisher was mounted and fully charged at the time of this visit
Appliances:
Refrigerator/freezer and microwave which were clean and noted to be operational. Washer and dryer were clean and noted to be operational.
Toxins:
Will be locked and inaccessible to clients
Water Temperature:
Hot water temperature is tested and is within regulatory requirements.
Medications, First Aid Kit & Manual:
First Aid kit with guide is stored in the medication cabinet. Medication will be stored in locked metal cabinet
Client and Staff Files:
Records will be kept in office

A Component III Orientation was conducted during this Pre-Licensing visit. Applicant demonstrated a clear, concise and comprehensive knowledge of medication protocols, documentation and preventative protocols.

The Pre-Licensing inspection has been completed. It appears this facility meets the requirements for licensure. The license will be granted upon completion of a final review and approval from the Application Specialist.



An exit interview was conducted and a copy of this report will be emailed..
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
LIC809 (FAS) - (06/04)
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