<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006075
Report Date: 01/27/2022
Date Signed: 01/27/2022 01:21:44 PM

Document Has Been Signed on 01/27/2022 01:21 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:HOME SWEET HOMECAREFACILITY NUMBER:
306006075
ADMINISTRATOR:MENJIVAR, YESENIAFACILITY TYPE:
735
ADDRESS:8722 KATELLA BLVDTELEPHONE:
(714) 827-3990
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 5DATE:
01/27/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Yesenia Menjivar, LicenseeTIME COMPLETED:
11:20 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On this day, Licensing Program Manager (LPM) Alisa Ortiz and Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an announced visit to the facility for the purpose of conducting the pre-licensing verifications required for a change of ownership.
At approximately 9:15am, CCLD staff were greeted upon arrival by the applying licensee Yesenia Menjivar and were screened according to the facility’s COVID-19 procedures and granted entry. Facility is a green one-story house with five (5) bedrooms, three (3) of which are assigned to clients and shared, the remaining being occupied by live-in staff.
CCLD staff started by touring the physical plant. Current clients in care are absent from the facility while attending work or their assigned day program. Current census is 5 for a total capacity of 6 clients. Hallways are clear of clutter and debris; adequate furnishing elements are being provided to the clients. The two (2) shared bathrooms used by clients are free of toxics and non-slip maps and grab bars have been installed. An ample supply of linen is available to clients. Smoke detectors are present in each room and found to be operational.
The exterior of the physical plant is also free of clutter and debris. Gates at each side of the house are kept latched but can be easily opened in case of evacuation.
An ample supply of perishable and non-perishable food is on hand as well as emergency food and water supply, stored in the garage. Weekly nutrition plans are displayed in the kitchen. A sufficient supply of PPE is also stored in the garage. Cleaning supplies and toxics are kept under lock. A 30-day supply of medication assigned to each client is stored and locked in the office along with clients’ records.
Emergency disaster plan will be updated and reviewed at the post-licensing stage. Mitigation plan has been submitted and approved by Community Care Licensing (CCL).
A Component III has been conducted on this day with prospective licensee Yesenia Menjivar. The facility is ready to be licensed. An exit interview and a copy of the report were provided at the time of the exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2022
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 1