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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006323
Report Date: 07/03/2024
Date Signed: 07/03/2024 04:46:54 PM

Document Has Been Signed on 07/03/2024 04:46 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:PACIFIC UNION HOME CAREFACILITY NUMBER:
306006323
ADMINISTRATOR/
DIRECTOR:		LORICO, MERVIN DAVEFACILITY TYPE:
735
ADDRESS:4442 ACORN COURTTELEPHONE:
(310) 713-4305
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 4CENSUS: 0DATE:
07/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Edwin PanganibanTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On July 3, 2024, at 1:40pm, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Licensee (LI) Edwin Panganiban and explained the purpose of the visit.

The facility is licensed to operate for four (4) ambulatory clients. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) clients bedrooms, one (1) staff bedroom, one (1) staff office, two (2) bathrooms, living room, dining room, kitchen, attached 2-car garage, and an outside covered patio area. Currently, the facility has zero (0) clients.

LPA Kim toured indoor and outdoor of the physical plant with LI Panganiban. There are no obstructions or bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Client Room 1, Client Room 2, Client Room 3, Client Room 4, and Staff Room 1. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at the shared bathroom at 106.1 degrees F and in the private bathroom at 105.2 degrees F. A comfortable temperature of degrees 78 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected there is a seven-day supply of non-perishable food available and maintained properly. Emergency food, water, and supplies are stored in the garage. The facility has one (1) fire extinguisher that is charged and smoke/carbon monoxide detectors were operable. A working telephone (714)371-4009 remains available. First Aid Kit contained all the necessary elements.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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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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: PACIFIC UNION HOME CARE
FACILITY NUMBER: 306006323
VISIT DATE: 07/03/2024
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During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and clients. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). The facility conducts Fire/Safety Drill quarterly.

LPA conducted an audit of staff files (S1) that were all in order and complete. LPA Kim conducted 1 staff interview.

An exit interview was conducted and a copy of this report along was provided to Licensee Edwin Panganiban.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC809 (FAS) - (06/04)
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