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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006104
Report Date: 04/26/2023
Date Signed: 04/26/2023 02:57:12 PM

Document Has Been Signed on 04/26/2023 02:57 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:ST. AGNES HOME CARE, LLCFACILITY NUMBER:
306006104
ADMINISTRATOR:AGNES, DJHOANA Q.FACILITY TYPE:
735
ADDRESS:1019 S ADAMS AVENUETELEPHONE:
(657) 248-7304
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 4CENSUS: 3DATE:
04/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Marilyn BalmesTIME COMPLETED:
03:15 PM
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Licensing Program Analysts (LPAs) Claudia Gutierrez and Dwayne Mason Jr. arrived at St. Agnes Home Care, LLC to conduct an unannounced Required 1 Year Inspection. At 12:15pm, LPAs Gutierrez and Mason were greeted and granted entry by Administrator (AD) Marilyn Balmes.

Structure:
The facility is a one-story home with four resident bedrooms, 2 bathrooms, living room, kitchen, staff bedroom, and an attached two car garage. LPAs observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the living room area. There is a back yard with one exit gate on one side of the house. There are two shaded seating areas in the backyard. LPAs did not observe any obstacles or hazards in the backyard.

Client Bedrooms
All resident bedrooms had the required furnishings. LPAs observed all resident beds had linens and blankets. LPAs observed all windows were screened.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked beneath the kitchen sink.

Medications, First-Aid Kit & Book:
Medication is stored in a locked cabinet. First aid kit is stored with the medication. The first aid kit has all the required elements.

Appliances:
Gas 4 burner stove with 1 oven, 1 refrigerator, dish washer, microwave, washer, and dryer are operational.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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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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. AGNES HOME CARE, LLC
FACILITY NUMBER: 306006104
VISIT DATE: 04/26/2023
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Resident & Staff Files:
Records are kept locked in storage cabinet located in the kitchen. LPAs reviewed 3 client files and 2 staff files. LPAs interviewed 2 staff and 2 clients.

Fire Extinguisher & Disaster Drill:
The fire extinguisher is fully charged. Upon record review LPAs noted that last disaster drill was conducted on March 21, 2023.

Reading Material, Games, Equipment & Materials:
The facility has books, magazines, board games, karaoke, and exercise equipment kept in the living room and garage areas.

Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 120 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was posted and visible.

Food Service:
There is a supply of 2-day perishable and 7-day of non-perishable food on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Based on the observations made during today's visit, no deficiency is being cited as per Title 22 Division 6 Chapter 2 of the California Code of Regulations. An exit interview was conducted with AD Marilyn Balmes, and a copy of this report was provided during this visit.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC809 (FAS) - (06/04)
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