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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006250
Report Date: 03/29/2024
Date Signed: 03/29/2024 04:25:43 PM


Document Has Been Signed on 03/29/2024 04:25 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:ST. CLAIR SENIOR CAREFACILITY NUMBER:
306006250
ADMINISTRATOR:GARCIA, MARY JOY CFACILITY TYPE:
740
ADDRESS:830 SAINT CLAIR ST.TELEPHONE:
(562) 521-4966
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 3DATE:
03/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mary Joy Garcia, AdministratorTIME COMPLETED:
04:40 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit for the purpose of conducting a Required Annual Inspection. LPA was greeted and granted entry by administrator Mary Joy Garcia after introducing himself and stating the reason of the visit.

During the inspection, LPA and administrator conducted a tour of the physical plant and observed the following: The facility is a one-story home with four resident bedrooms, one staff room and two bathrooms. All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets and an adequate additional supply is present. The backyard has several shaded areas and the route of egress is free of clutter and obstructions. There are currently three residents in care at the facility, one of which is receiving hospice care. Residents are observed to be clean and appear well taken care of. Bathrooms faucets and toilets were operational. Water temperature was verified to be within acceptable range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. 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. Combined smoke and carbon monoxide detectors tested operational. There are three fire extinguishers present, all of which are observed to be fully charged with up-to-date maintenance. Medication, sharp items and cleaning supplies were confirmed to be inaccessible throughout the physical plant. The staff room and laundry area were observed to be locked by facility staff. The medication central storage was also observed to be secure. LPA reviewed three resident files and three staff files. LPA conducted or attempted three resident and two staff interviews.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. LPA provided consultation in the form of three Technical Assistance Advisory Notes. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024
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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