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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006075
Report Date: 02/03/2025
Date Signed: 02/03/2025 12:07:55 PM

Document Has Been Signed on 02/03/2025 12:07 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:HOME SWEET HOMECAREFACILITY NUMBER:
306006075
ADMINISTRATOR/
DIRECTOR:		MENJIVAR, YESENIAFACILITY TYPE:
735
ADDRESS:8722 KATELLA BLVDTELEPHONE:
(714) 827-3990
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 4CENSUS: 4DATE:
02/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Yesenia MenjivarTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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On this day Licensing Program Analysts (LPAs) Rose Ruppert and Fred Arias made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 4 ambulatory clients. The facility currently has 4 clients. Administrator (AD) Yesenia Menjivar conducted the facility tour. AD Menjivar has a valid certificate that expires on10/2/2026. AD provided updated liability insurance that expires on 2/22/2025.

LPAs along with Administrator Menjivar toured the facility at 8:20 AM. LPAs toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 4 client bedrooms, living room, dining room, and kitchen as well as 3 bathrooms and 1 staff room. 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 132.2 degrees F and 134.6 degrees F in all bathrooms. Client bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. LPAs toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPAs reviewed the emergency disaster plan and the plan is complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 12/7/2024. Outside grounds were toured. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of outings, painting, dancing and signing. There is shaded outdoor seating for clients. Exit gates are unlocked and operational. LPAs observed the emergency water supply. LPAs reviewed four client files and four staff files.
CONTINUED ON LIC 809C DATED 2/3/2025.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2025
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: HOME SWEET HOMECARE
FACILITY NUMBER: 306006075
VISIT DATE: 02/03/2025
NARRATIVE
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4 out of 4 client files were missing facility admissions agreements and 2 out 4 clients were missing physician's reports. Staff files reviewed were missing updated annual training. The last documented training is from January 2024. 2 out of 4 staff files reviewed were missing medical assessment/ TB records. LPAs reviewed medication storage and administration. Medications are stored in a locked closet. Medications are being administered per physician order.

LPA is recommending AD for a consultation with the Technical Support Program.

Based on the observations made during today’s visit, 3 deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 02/03/2025 12:07 PM - It Cannot Be Edited


Created By: Fred Arias On 02/03/2025 at 11:14 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HOME SWEET HOMECARE
FACILITY NUMBER: 306006075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on LPA observation, the water temperature for the bathrooms ranged between 132.2 F and 134.6 F which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/04/2025
Plan of Correction
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2
3
4
AD will adjust water temperature down between 105 F and 120 F by due date, AD will email with a picture of thermometer within the allowed temperature range.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Fred Arias
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 02/03/2025 12:07 PM - It Cannot Be Edited


Created By: Fred Arias On 02/03/2025 at 11:14 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HOME SWEET HOMECARE
FACILITY NUMBER: 306006075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, there are no facility admissions agreements for 4 out of 4 clients which poses a personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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The AD will email admissions agreements to LPA for review by POC due date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Fred Arias
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 02/03/2025 12:07 PM - It Cannot Be Edited


Created By: Fred Arias On 02/03/2025 at 11:33 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HOME SWEET HOMECARE
FACILITY NUMBER: 306006075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation requried by Section 85022.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the facility does not have an infection control plan in place which poses a potential health and safety risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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AD to send an infection control plan to LPA but POC due date
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Fred Arias
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025


LIC809 (FAS) - (06/04)
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