306006075-12-12-2022-22-AS-CDPO-CM2VNN-20221212153526

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006075
Report Date: 12/12/2022
Date Signed: 12/12/2022 03:36:04 PM

Document Has Been Signed on 12/12/2022 03:36 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 HOMECARE		FACILITY NUMBER:	306006075
ADMINISTRATOR:	MENJIVAR, YESENIA		FACILITY TYPE:	735
ADDRESS:	8722 KATELLA BLVD		TELEPHONE:	(714) 827-3990
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY: 4		CENSUS: 4	DATE:	12/12/2022
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	02:19 PM
MET WITH:	Staff on duty-Lina Raymundo		TIME COMPLETED:	03:55 PM

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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required post-licensing inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 2 staff were on duty, who contacted facility administrator (AD) Yesenia Menjivar about visit. AD Menjivar was unable to be present during time of visit due to taking a client to a medical appointment, however, provided consent for staff on duty (S1) Lina Raymundo to receive and sign report. As of 12/12/22, there is 1 active COVID-19 case in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted throughout the facility. LPA observed the Administrator's Certificate for Yesenia Menjivar, which expires on 10/22/24.

LPA De Perio toured the interior and exterior portions of the facility with S1. The facility is a single level structure and is licensed for 6 ambulatory clients ages 18 through 59. Currently, there are a total of 4 clients in care, of which 2 were only present during today's visit. The two clients who were not at the facility were at a job, and the other was attending a medical appointment. Facility is a level 2 facility. There are a total of 5 bedrooms, of which 4 are private client rooms, and 1 for live in staff. All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards.

Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. The restrooms were observed to be in good repair, toilets were operational. Water temperature in restrooms were measured at 107.8 degrees Fahrenheit and hand washing signs were also posted in each restroom.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to clients in care and located in a locked kitchen drawer. Fire extinguisher was charged, mounted and located in the kitchen corner. LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the kitchen. Facility had back-up emergency food and water supply, located in the kitchen and in the garage.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

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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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: HOME SWEET HOMECARE	FACILITY NUMBER: 306006075
	VISIT DATE: 12/12/2022

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For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which was self-closing and self-latching.
LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in garage.. Medications were locked and located in the staff room. Toxins were also observed to be locked and inaccessible to clients in care and located in the garage. No bodies of water were observed.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with staff on duty and AD Menjivar via phone. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued.

LPA De Perio discussed with AD Menjivar to review, and subscribe for emails regarding the Provider Information Notices (PINs) as well as to attend the CCLD Informational Calls to ensure that facility and staff are up to date. The PINs can be accessed at: www.ccld.ca.gov.

LPA De Perio discussed the California Code of Regulations Section 85075.4 Observation of the Client and Sections 80061 and 85061 Reporting Requirements with staff on duty.

LPA De Perio advised staff on duty and AD Menjivar to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with staff on duty and a copy of this report, and copies of the regulations discussed were provided to the facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

LIC809 (FAS) - (06/04)

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