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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006188
Report Date: 09/09/2025
Date Signed: 09/09/2025 04:44:43 PM

Document Has Been Signed on 09/09/2025 04:44 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/
DIRECTOR:		ZANO, ROMEOFACILITY TYPE:
735
ADDRESS:1640 W. CAMILE PLACETELEPHONE:
(714) 836-4571
CITY:SANTA ANASTATE: CAZIP CODE:
92703
CAPACITY: 6CENSUS: 4DATE:
09/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator Romeo ZanoTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On September 9, 2025, Licensing Program Analysts (LPAs) Brandon Lopez and Garlli Tat made an unannounced visit to the facility to conduct the required annual inspection. LPAs were greeted and granted entry into the facility by staff after explaining the purpose for visit. Administrator (AD) Romeo Zano was notified via telephone and later arrived to assist with the inspection. LPAs observed that Romeo Zano has a valid Administrator certificate which expires on January 10, 2027.

The facility is an Adult Residential Facility (ARF) licensed for six ambulatory clients. The facility is a single story home with three shared client bedrooms, two staff bedrooms, two bathrooms, a living room, a dining room, a kitchen, and a staff office. LPAs, accompanied by the AD, conducted a tour of the interior portion of the facility. On today's visit, there were four clients and three staff present. LPAs inspected the three client bedrooms and observed them to be free of hazards. LPAs observed client bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPAs observed client beds to have clean linens and blankets. LPAs observed additional linens to be stored in a hallway closet. LPAs inspected the one client bathroom. LPAs observed three chemicals stored in an unlocked cabinet under the bathroom sink. The faucet and toilet was operational. Hot water temperature measured 104.3 degrees Fahrenheit. LPAs observed the two staff bedrooms and the staff office to be free of any hazards. LPAs observed one staff bedroom to have a three day emergency food and water supply. LPAs also observed chemicals and toxins to be stored in a locked cabinet in a staff bedroom. LPAs observed kitchen knives and sharps to be stored in a different locked cabinet in the staff bedroom.

LPAs observed the facility has a two day perishable and a seven day nonperishable food supply on hand in the kitchen. CONTINUED ON 809-C
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 09/09/2025
NARRATIVE
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LPAs observed kitchen appliances to be clean and operational. LPAs observed the four burner gas stove lights unassisted. LPAs observed a Fire Extinguisher to be mounted on the wall by the kitchen. The Fire Extinguisher was observed to be charged and serviced as of December 17, 2024. LPAs tested the individual smoke detectors/carbon monoxide detectors which tested operational. LPAs observed the facility conducted their last emergency disaster drill on August 10, 2025. LPAs observed the centrally stored medication to also be kept in a locked medicine cart located in a staff bedroom. LPAs observed the facility has a First Aid Kit stored in the staff bedroom and it had all the required components.

LPAs, accompanied by the AD, conducted a tour of the exterior portion of the facility. The exterior portion was observed to be free of hazards and obstructions. LPAs observed a shaded outdoor seating area with furniture for client use. LPAs observed the perimeter gates to be self latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPAs reviewed all four client files. All the required documentation were present and current in the client files reviewed. LPAs reviewed clients' medication and medication records. LPAs observed that staff were not correctly documenting the medication administration records for Client #3 (C3) Melatonin 5 MG tablet and Client #4 (C4) Loratadine 10 MG tablet. The facility handles Personal and Incidental expense monies (P&I) for four clients. LPAs reviewed the P&I for the four clients. LPAs reviewed four staff files. All staff are background cleared and associated to the facility.

Based on the observations made during today's visit, deficiencies are being cited on the attached LIC809-Ds. An exit interview was conducted with Administrator Romeo Zano. A copy of the report and Appeal Rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/09/2025 04:44 PM - It Cannot Be Edited


Created By: Brandon Lopez On 09/09/2025 at 04:30 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: 09/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPAs observed one clorox bottle, one scrubbing bubbles bottle, and one comet container, stored in an unlocked bathroom cabinet under the sink.
POC Due Date: 09/10/2025
Plan of Correction
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AD agreed to conduct an in service training with staff regarding the proper storage of chemicals. AD agreed to provide proof of training to LPA via email or fax by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2025 04:44 PM - It Cannot Be Edited


Created By: Brandon Lopez On 09/09/2025 at 04:30 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: 09/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPAs observed that staff were not correctly documenting the medication administration records for Client #3 (C3) Melatonin 5 MG tablet and Client #4 (C4) Loratadine 10 MG tablet.
POC Due Date: 09/26/2025
Plan of Correction
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AD agreed to conduct an in service training with staff regarding the proper document of clients' medication adminstrator records. AD agreed to provide proof of training to LPA via email or fax by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2025


LIC809 (FAS) - (06/04)
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