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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006236
Report Date: 08/09/2023
Date Signed: 08/09/2023 11:16:44 AM

Document Has Been Signed on 08/09/2023 11:16 AM - 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:FULLERTON SWEET HOMEFACILITY NUMBER:
306006236
ADMINISTRATOR:MOON, DONGHYUNFACILITY TYPE:
740
ADDRESS:516 S JENSEN WAYTELEPHONE:
(714) 345-5478
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 6CENSUS: DATE:
08/09/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Donghyun Moon - AdministratorTIME COMPLETED:
11:36 AM
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On July 26, 2023, following a Pre-Licensing inspection, Licensing Program Analyst, Dwayne Mason Jr. assigned seven corrections for Administrator (AD) Donghyun Moon to complete by close of business (COB) August 25, 2023 in order to be ready for licensure.
LPA returned to the facility on August 9, 2023 and was granted entry to the facility by the AD at 10:33 am. LPA discussed with the AD the purpose of the visit.
LPA is conducting a follow-up Pre-Licensing visit with the purpose of verifying the following corrections:
1. Bedroom 3 needs to be equipped with all necessary furnishings
2.The screen in Bedroom 2 needs to be repaired or replaced
3.The facility needs to be stocked with a 7-day non-perishable food supply
4.Replace See Something, Say Something sign with the 20" x 26" PUB475
5.The two unsanitary refrigerators need to be removed from the facility
6.Provide a shaded outdoor seating area for residents to use for activities
7.LPA Mason will contact CAB regarding the unlabeled bathroom in Bedroom 3 and will notify the applicant of any necessary actions to be completed.
Upon inspection, LPA observed that:

1. Bedroom 3 is equipped with all necessary furnishings


2.The screen in Bedroom 2 was replaced
3.The facility is stocked with 7-day non-perishable food supply
4.See Something, Say Something sign (PUB475) is the appropriate size
5.Both unsanitary refrigerators were removed from the facility
6.There is a shaded outdoor seating area for residents to use for activities
7.AD and LPA consulted with Fire Inspector. AD converted Bedroom 3 bathroom back to a closet

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2023
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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