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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006331
Report Date: 06/06/2024
Date Signed: 06/06/2024 01:20:55 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/06/2024 01:20 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: 2DATE:
06/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Isabel Ybarra, Lead Direct Service Provider, Amelita DelaCruz, DSP, Juanito DelaCruz, DSP, Laura Palomino, Facility AdministratorTIME COMPLETED:
01:25 PM
NARRATIVE
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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced Annual Required-1 year inspection visit. LPA was granted entry by Direct Service Provider Amelita DelaCruz. LPA Quiroz called Licensee Kevin Clark and discussed purpose of today's visit. Sister Facility Administrator (AD) Laura Palomino and Lead Direct Service Provider Isabel Ybarra (LDSP) arrive during today's visit.
AD Palomino indicated AD Gerald Jones is on vacation and that AD Palomino is providing AD coverage during his absence. AD Palomino indicated she will be at the facility premises more than 20 hours per week until AD Jones resumes AD duty. AD Certificate for Gerald Jones expires on 6/23/2024.
This is a leveI 4G Facility licensed for a capacity of 4 ambulatory clients only, providing services to Adult clients with Developmental Disabilities ages 18-59. At 9:09am, LPA Quiroz reviewed whether the following is in compliance: licensee is operating the facility within the conditions and limitations, which are specified on the license, including the capacity limitation.
At 9:35am, LPA along with DSP Amelita DelaCruz conducted the tour inspection. A tour of the interior and exterior of the facility and physical plant were inspected, including but not limited to testing hot water temperature in resident and common bathrooms. The client bathrooms water tested and measured between 105.9- 114.8 degrees Fahrenheit. All smoke detectors, carbon monoxide, were operational and functional.
The facility is a 2 story home. The home consists of: 4 client private bedrooms, 2 private restrooms for clients and 1 restroom for visitors and staff, living room, kitchen with dining area, break room, 2 car garage and shaded back yard area with table and chairs for client and visitor enjoyment.
Between 10:05am-12:40pm, LPA reviewed 6 of 6 staff records, 2 of 2 client records, 2 of 2 centrally stored medication records and 2 of 2 Personal & Incidental funds records (P&I). Staff records, centrally stored medications were found to be within Title 22 California Code of Regulations (CCR). LPA observed missing physician report for Client 1 and missing P&I LIC 405- Records of client's/Resident's safeguarded cash resources for Client 2. (SEE LIC 809-D)
CONTINUED ON LIC 809-C PAGE...
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
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 3


Document Has Been Signed on 06/06/2024 01:20 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2024
Section Cited
CCR
80073(a)

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80073(a): Telephones-(a)All facilities shall have telephone service on the premises. This requirement is not met as evidenced by LPA Quiroz dialed facility number provided by AD Palomino (714)583-9491, "Welcome to Verizon wireless. CONTINUE
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AD Palomino will call Verizon wireless and schedule appointment to repair telephone line by POC due date of 6/14/2024 COB.
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CONT...Your call can not be completed as dialed." Non working phone line was verified with AD Palomino, Lead DSP Ybarra and 2 of 2 staff working on today's date. This poses a potential risk to clients in care.
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Type B
06/14/2024
Section Cited
CCR80070(b)(8)

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Client Records-80070(b)(8)(14)Each record must contain information including, but not limited to, the following:(8) Medical assessment, including ambulatory status, as specified in Section 80069. (14)An account of the client's cash resources, personal CONTINUE...
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AD Palomino will submit copy of Client 1's physician report, and updated LIC 405 form for Client 2 to CCLD by POC due date of 6/14/2024.
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CONT...property, and valuables entrusted as specified in Sect 80026.This requirement is not met as evidenced by: During records review, LPA Quiroz observed missing physician report for Resident 1 and missingLIC 405 Records of client's/Resident's safeguarded CONTINUE...
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cash resources. This was verified with AD Palomino. This poses a potential risk to clients in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: 06/06/2024
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CONTINUED... LPA verified if facility is providing a comfortable temperature due to hot/cold weather condition. Facility has a working centralized heater and air conditioner to use for the cold or hot weather as needed. The temperature inside the facility was recorded to be 73 degrees Fahrenheit.
LPA reviewed facility telephone number (714)583-9491 is not in working condition. (SEE LIC 809-D) There is provision of sufficient lighting; no exit obstructions or potential hazards. Poisons, toxic substances, and other dangerous objects were noted to be secured in kitchen cabinet area and inside garage not accessible to clients in care. Kitchen knives were stored and secured in kitchen cabinet, not accessible to clients in care. The Outside grounds were inspected during facility tour. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.
AD Palomino reported offering the following indoor and outdoor activities at the facility according to weather conditions: "Guitar arcade in the garage area, neighborhood walks, play baseball at the park, yoga classes, swimming through orange coast college, karaoke, facility BBQs and birthday celebrations."
One fire extinguisher observed and fully charged. AD Palomino indicated testing of fire extinguisher scheduled for this month. AD reports fire drills are conducted with staff and clients. Last facility fire drill scheduled to be conducted on today's date, June 6, 2024 with staff and clients.
Plentiful basic hygiene items and linen supply were available. First Aid KIT and other aide supplies were observed to be stored in secured cabinet in dining room area. Furnishing cleanliness and state of repair, and fixtures were examined. Nonskid mats were observed in client restrooms. Operational and functional Washer and Dryer observed in the garage area. Facility observed to have emergency food and water and PPE readily available for clients in care.

Based on the observations made during today’s visit, Facility is being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with AD Laura Palomino, and a copy of this report along with the Appeal Rights, LIC 809-D page, LIC 858 and LIC 859 were provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3