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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006188
Report Date: 09/18/2023
Date Signed: 09/18/2023 02:11:28 PM

Document Has Been Signed on 09/18/2023 02:11 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: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: 5DATE:
09/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Romeo ZanoTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility was greeted and granted entry by caregiver and LPA explained the nature of the visit. Romeo Zano, Administrator arrived shortly after and me with LPA.
Five clients reside at this facility, there was three clients at the time of visit. LPA began the tour of the inside and outside of the facility. LPA observed required department postings throughout the facility. There is a minimum of one week of non-perishables foods and two days of perishables foods available. LPA inspected that medication are centrally stored in a safe locked storage cabinet located in staff break room. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care. LPA measured the hot water temperature which measured 106.6 Fahrenheit degrees. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked in laundry unit. The facility has an available clean supply of linens. LPA inspected client’s bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for clients in their bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there is shaded seating areas for client’s enjoyment. LPA observed a fire extinguisher with service date of November 02, 2022, in kitchen. Fire drills conducted every two weeks and LPA verified last Fire Drill was conducted on September 14, 2023. LPA began review of records. LPA reviewed five clients’ records. All the required documentation was present and current in client’s files reviewed. The facility P&I records were reviewed. LPA observed that an individual log is maintained for each client. All monies are accounted for and attached receipts for record keeping. LPA reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate.
Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the Administrator, and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2023
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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