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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006323
Report Date: 07/03/2023
Date Signed: 07/03/2023 03:36:34 PM

Document Has Been Signed on 07/03/2023 03:36 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PACIFIC UNION HOME CAREFACILITY NUMBER:
306006323
ADMINISTRATOR:LORICO, MERVIN DAVEFACILITY TYPE:
735
ADDRESS:4442 ACORN COURTTELEPHONE:
(310) 713-4305
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 4CENSUS: 0DATE:
07/03/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Mervin LoricoTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Applicant (AP) Mervin Lorico, discussed the purpose of the inspection, and toured the facility. Facility is to operate an Adult Residential Facility. Application was submitted to Community Care Licensing on 02/21/2023. This is a change of ownership and change of facility type with no persons in care. However, AP stated that this is an initial application, the property was vacant prior to AP taking possession, and that this facility is not related to the licensee who previously occupied this property.

During the inspection, LPA and AP observed the following: Structure: this is a one-story home. Facility is a 5-bedroom, 2-bathroom, one-story home with attached garage that is being used for storage. Facility telephone number is (714) 381-4009. Client Bedrooms: the 4 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Lamps, chairs, linens, and storage for each client bedroom inspected. Staff Bedrooms: the 1 staff bedroom is spacious and will easily accommodate the staff’s furnishings. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 110.6 to 113 F degrees. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: 7 days nonperishable food supply reviewed. AP stated they will obtain 2 days perishable food supply prior to accepting clients. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested, including the smoke detectors and carbon monoxide detectors. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: will be locked in the kitchen cabinet. Toxins: observed locked in the garage. Medication closet is locked. First-Aid Kit & Activity Supplies: observed and available. Client & Staff Files: this is an initial inspection. LPA observed storage area for client and staff files. Fire clearance was approved by Orange County Fire Authority on 03/09/2023. Backyard exit gate is operational and unlocked. Back yard has shaded area for outdoor activities and sufficient seating for clients. Component III was completed with AP during today’s inspection. AP will obtain liability insurance once application is approved.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PACIFIC UNION HOME CARE
FACILITY NUMBER: 306006323
VISIT DATE: 07/03/2023
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During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AP was informed today that the facility is ready for licensure and final approval will be processed by the CAB supervisor in Sacramento. An exit interview was conducted and a copy of this report was discussed with and provided to AP.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023
LIC809 (FAS) - (06/04)
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