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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006331
Report Date: 05/09/2023
Date Signed: 05/09/2023 04:11:25 PM

Document Has Been Signed on 05/09/2023 04:11 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:COMMITMENT TO COMPASSION HOME LLCFACILITY NUMBER:
306006331
ADMINISTRATOR:JONES, GERALDFACILITY TYPE:
735
ADDRESS:17882 SANTA MARIANA STTELEPHONE:
(818) 384-9331
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 4CENSUS: 0DATE:
05/09/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kevin ClarkTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Lydia Martinez made an announced visit for the purpose of conducting a Pre-Licensing inspection. LPA met with Applicant (AP) Kevin Clark. An initial application to operate an Adult Residential Facility (ARF) for four (4) Ambulatory clients was received on 03/16/2023.
Structure:
The facility is a two story home with an attached two car garage that will be used for storage. There are 4 bedrooms on the second floor, 3 bathrooms, a dining room, a living room, and a kitchen. Bedrooms are spacious and will easily accommodate client's furnishings. There is a large back yard with 1 exit walkway on each side of the house. There is a covered patio with table and chairs for clients and visitor's use.
Fire clearance:
Was cleared on 03/31/2023.
Air/Heating:
Central air/heating system installed with a central panel to control entire house.
Bedrooms:
Bedrooms will be private and accommodate 4 clients.
Bedrooms Staff:
Facility will have hourly staff; no live-in.
Bathrooms:
Bathrooms have a working toilet, wash basin, and showers.
Linens & Hygiene Supplies:
Adequate supply of linen stored in hallway closet upstairs. Hygiene supplies to be stored in locked medication closet.
Emergency Phone Numbers, Exit Plan & Menu:
Posted & available for review is Emergency Disaster Plan with means of exiting; Emergency phone numbers listed. Menus will be posted and available. Menus to be prepared one week prior and listed for food served for one week. Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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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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: COMMITMENT TO COMPASSION HOME LLC
FACILITY NUMBER: 306006331
VISIT DATE: 05/09/2023
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Food Service:
Applicant understands facility will have an adequate supply of 7-day non-perishable and 2-day perishables at all times when clients are present.
Smoke Detectors:
Smoke detectors and carbon monoxide alert systems are hardwired, were tested and found operational.
Appliances:
Electric four-burner stove, single oven, 1 refrigerator, microwave, washer, and dryer are clean and noted to be operational.
Toxins:
All and any toxic chemicals, cleaning solutions and disinfectants will be made inaccessible to clients and will be locked and stored in locked garage.
Water Temperature:
Hot water in bathroom is within regulatory requirements.
Medications, First-Aid Kit & Book:
Medication locked and stored in locked closet near dining room. First Aid Kit observed contained all required items
Client & Staff Files:
Records will be kept locked with medication cabinet.
Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation.
Component III:
Component III is waived during visit as Applicant is Licensee/Administrator of other licensed facilities.

All elements verified by LPA appear to be in compliance and the facility is ready to be licensed. The license will be granted upon completion of a final review and approval from the Application Specialist. An exit interview was conducted and a copy of this report will be sent to the email on file.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC809 (FAS) - (06/04)
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