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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006188
Report Date: 09/14/2022
Date Signed: 09/14/2022 03:26:00 PM

Document Has Been Signed on 09/14/2022 03:26 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:SAMANTHA'S HOMEFACILITY NUMBER:
306006188
ADMINISTRATOR:ZANO, ROMEOFACILITY TYPE:
735
ADDRESS:1640 W. CAMILE PLACETELEPHONE:
(714) 836-4571
CITY:SANTA ANASTATE: CAZIP CODE:
92703
CAPACITY: 6CENSUS: DATE:
09/14/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Licensure Maria Kabiling and Susan KabilingTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Shobhana Frank conducted announced inspection for the purpose of conducting a pre-licensing inspection and COMP III. LPA met with licensure Maria Dolor Kabiling and Susan Kabiling and discussed the purpose of the inspection. LPA Frank toured the facility along with the Maria Dolor Kabiling.
Facility is to operate an Adult Residential Facility ages 18 to 59. Application was submitted to Community Care Licensing on 06/02/22. There were 2 residents present during the inspection.
LPA observed COVID - visitation station equipped with hand sanitizer, thermometer, Gloves, visitors log, COVID posters throughout the facility.
During the inspection, LPA observed the following.
This is a single story home. Facility is a 3 bedroom and 2 bathroom, house with attached garage that is
being used for storage. There is a back yard with a patio cover for the residents. Backyard exit gate is operational and unlocked. Backyard has shaded area for outdoor activities and
sufficient seating for residents. LPA observe the facility to be clean and in good repair, Physical Plant and Safety of Environment/Operational as CCL Requirements.
Facility telephone number is 714-836-4571. Residents bedrooms are spacious and easily accommodate the residents furnishings. Lamps, chairs, linens, and storage for each residents bedroom. Bathrooms were inspected and observed to be clean, faucets and toilets were operational. Water temperature was tested 107.5 F degrees. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers 323-717-6675, Exit Plan & Menu: Reviewed. Food Service. 2 days perishable and 7 days nonperishable food supply observed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detector/carbon monoxide detector. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked/stored in the kitchen cabinet. Toxins: observed in the locked cabinet in the garage. Medication cabinet is locked. First-Aid Kit & Activity Supplies: observed and available. Fire clearance was approved by Orange County Fire Authority on 7/18/22.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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: SAMANTHA'S HOME
FACILITY NUMBER: 306006188
VISIT DATE: 09/14/2022
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Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked/stored in the kitchen cabinet. Toxins: observed in the locked cabinet in the garage. Medication cabinet is locked. First-Aid Kit, PPE & Activity Supplies: observed and available.
Licensure was informed today that the facility is ready for licensure and final approval will be processed by the CAU supervisor in Sacramento.
An exit interview was conducted and a copy of this report was discussed with and provided to Licensure.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC809 (FAS) - (06/04)
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