306006188-9-10-2024-22-AS-ARJR-D8YV3K-20240910160452

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006188
Report Date: 09/10/2024
Date Signed: 09/10/2024 04:04:59 PM

Document Has Been Signed on 09/10/2024 04:04 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 HOME		FACILITY NUMBER:	306006188
ADMINISTRATOR/ DIRECTOR:	ZANO, ROMEO		FACILITY TYPE:	735
ADDRESS:	1640 W. CAMILE PLACE		TELEPHONE:	(714) 836-4571
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92703
CAPACITY: 6		CENSUS: 4	DATE:	09/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:05 PM
MET WITH:	Susan Kabiling-Caregiver		TIME VISIT/ INSPECTION COMPLETED:	04:20 PM

NARRATIVE

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Caregiver Susan Kabiling.

For today’s visit, LPA observed a total of four clients in care and two staff members on duty.

LPA observed the Administrator's Certificate for facility AD Romeo Zano which expires on January 10, 2025.

LPA Ramirez toured the interior and exterior portions of the facility with Caregiver Kabiling. The facility is a one-story home and is licensed for six ambulatory clients. There are a total of four bedrooms of which three are for clients and one for staff. LPA Ramirez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. LPA observed all windows were screened. Smoke and carbon monoxide detectors were tested and operational. There are a total of two restrooms of which one is for clients and one for staff. Restrooms were observed to be in good repair, toilets were operational and non-skid floor mats were provided. Water temperature tested between 105.2-106.3 degrees Fahrenheit.

Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Fire extinguisher was observed to be fully charged and located by the living room/dining room. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable.

CONTINUED ON LIC809-C..

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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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Document Has Been Signed on 09/10/2024 04:04 PM - It Cannot Be Edited

Created By: Alvaro Ramirez Jr. On 09/10/2024 at 03:19 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SAMANTHA'S HOME	FACILITY NUMBER: 306006188
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85087.2(b)

Outdoor Activity Space

(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. In the backyard LPA observed a table and chairs; however, LPA did not observe a shaded area.
	POC Due Date: 09/13/2024
	Plan of Correction
1 2 3 4	Licensee to provide a shaded area and email LPA proof by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Sheila Santos

LICENSING EVALUATOR NAME:

Alvaro Ramirez Jr.

LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SAMANTHA'S HOME	FACILITY NUMBER: 306006188
	VISIT DATE: 09/10/2024

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LPA Ramirez observed the emergency disaster and evacuation plan, which is located by the dining room. Facility had back-up emergency food and water supply. LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to clients in care.

For the exterior portion, LPA observed patio furniture, and observed that the grounds were free of any hazards. During today's visit LPA did not observed a shaded area. There is one gate in the backyard, which both is self-closing and self-latching. No bodies of water were observed.

LPA reviewed four of four client files and three staff files. LPA also reviewed client money and ledger for four of four clients. LPA interviewed four clients and two staff.

During today's visit LPA observed clients' in their bedroom playing with their tablet and/or watching television in the living room.

For today's visit one deficiency was issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Caregiver Kabiling.

A copy of this report was provided at the time of exit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC809 (FAS) - (06/04)

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