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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006132
Report Date: 01/15/2025
Date Signed: 01/15/2025 04:23:19 PM

Document Has Been Signed on 01/15/2025 04:23 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:BEVERLY HOMEFACILITY NUMBER:
306006132
ADMINISTRATOR/
DIRECTOR:		CHEA, PAULFACILITY TYPE:
735
ADDRESS:1183 W. CHATEAU AVETELEPHONE:
(714) 215-4396
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: 2DATE:
01/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Paul CheaTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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On 01/15/2025 Licensing Program Analyst (LPA) William Vanegas made an unannounced visit for the purposes of conducting an annual visit. Upon arrival LPA was greeted and granted entry by Licensee Paul Chea. LPA Vanegas explained the purpose of the visit and conducted a tour of facility and observed the following.

This is a one storied home with four bedrooms that are client rooms, and two bathrooms, and an attached two car garage. LPA Vanegas observed the kitchen area to be clean and free of debris. LPA Vanegas observed a two day supply of perishable food and a seven day supply of non-perishable food. LPA Vanegas observed a gas stove, dishwasher, microwave, and refrigerator to all be in good repair and working condition.
LPA Vanegas observed fire extinguisher to be fully charged and up to date. LPA Vanegas observed the smoke detectors and carbon monoxide detectors to be operational. LPA Vanegas observed client rooms to have all the required furnishings such as a lamp, chest drawer, bed, proper closet space, and linens in good repair meaning no strains or tears.

LPA Vanegas conducted a tour of the outside of the facility and observed the following there is an outdoor shaded seating area. Side doors are self latching and unlocked, no obstructions are in exit routes and there is enough space to participate in outdoor activities. LPA Vanegas observed emergency food and water in garage and toxins looked away separate from food products. Washer and Dryer are functional and in good repair.

LPA Vanegas reviewed three staff files and two resident files and all files (Staff and Client) contained all the proper paperwork that is required. LPA reviewed P&I with Licensee and all P&I is correctly documented and all balances add up to the correct documented balance.
CONTINUED ON LIC809C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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 2
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: BEVERLY HOME
FACILITY NUMBER: 306006132
VISIT DATE: 01/15/2025
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LPA Vanegas reviewed first aid kit, and first aid kit contained all the required materials such as a first aid manual, scissors, adhesive tape, bandages, and a thermometer. LPA Vanegas interviewed one staff member and one clinet. LPA Vanegas reviewed medications and medications log. Per LPA Vanegas review medications are being administered and documented per physicians orders.

Based on the observations made during today’s inspection, deficiencies are not being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC809 (FAS) - (06/04)
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