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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006191
Report Date: 11/05/2024
Date Signed: 11/05/2024 01:40:52 PM

Document Has Been Signed on 11/05/2024 01:40 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:HAILEY PRISCILLA HOMEFACILITY NUMBER:
306006191
ADMINISTRATOR/
DIRECTOR:
KABILING, MARIA DOLOR G.FACILITY TYPE:
735
ADDRESS:2427 E. LINCOLN AVENUETELEPHONE:
(714) 956-5662
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 5DATE:
11/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Perlito BanaticlaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to conduct a Required - 1 year inspection. LPA was allowed entry into the home and met with House Manager, Perlito Banaticla. Administrator (AD) Maria D. Kabiling's Certificate expired on 08/08/2024. LPA confirmed/verified AD has submitted renewal application.
There are three of five Clients present during today's visit. LPA, along with House Manager Banaticla toured the physical plant. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked and toilets and water faucets worked properly and shower was free of mold/mildew. Hot water temperature was within regulatory requirements. Client bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Kitchen is clean and organized. Perishable and non-perishable food supply was checked and adequately stocked. Appliances are operational during today's visit. LPA observed sharps and cleaning supplies were inaccessible to the clients. Smoke detectors and carbon monoxide detector tested operational; Fire extinguisher was fully charged and mounted. No bodies of water were observed outside. Walkways around the home were clear of hazards. Exit gate to alley was unlocked. LPA observed First Aid kit contained required items. Last Emergency Fire Drill was conducted on 10/31/2024 and are conducted monthly. LPA observed emergency supplies including food and water. LPA reviewed five Client files and two staff file. Files contained required documentation per regulations. Medication was observed to be in a centrally stored location and medication reviewed appeared to have been dispensed accurately. P & I money matched facility ledger. Liability and Surety Insurance certificates are current. LPA observed board games, movies, and exercise machine for clients use.

Based on observations made during today’s visit, no deficiencies are being cited. This report was discussed with House Manager and a copy was sent to email on file.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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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