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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006116
Report Date: 05/07/2024
Date Signed: 05/07/2024 10:48:27 AM


Document Has Been Signed on 05/07/2024 10:48 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:FLOWERS FAMILY CAREFACILITY NUMBER:
306006116
ADMINISTRATOR:MARTINEZ, JONATHANFACILITY TYPE:
740
ADDRESS:1009 W 20TH ST.TELEPHONE:
(949) 274-0634
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY:6CENSUS: 4DATE:
05/07/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Dominga SantillianTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced Plan of Correction (POC) visit to follow up on citations issued on 04/10/2024 and 04/24/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit.

*Deficiency cited under Title 22 Regulation 87465(h)(2) pertaining to Centrally Stored Medications has been cleared. During today's visit, medications are secured in the medication closet. Licensee has complied with the POC.

*Deficiency cited under Title 22 Regulation 87705(f)(2) pertaining to Care of Persons with Dementia has been cleared. During today's visit, supplements are secured. Licensee has complied with the POC.




*Licensee has been advised to maintain compliance in all previously cited items.


Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
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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