<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006334
Report Date: 11/08/2023
Date Signed: 11/08/2023 10:36:32 AM

Document Has Been Signed on 11/08/2023 10:36 AM - 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LANCE CARE HOMEFACILITY NUMBER:
306006334
ADMINISTRATOR:SAYAT, RICHARDFACILITY TYPE:
735
ADDRESS:1311 LANCE DRIVETELEPHONE:
(657) 235-8232
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 4CENSUS: DATE:
11/08/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Administrator - Richard Michael SayatTIME COMPLETED:
10:55 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Dwayne Mason Jr made an announced inspection to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility at and was greeted by Administrator Richard Michael Sayat, Backup Administrator Anna Mallari and Licensee Francis Mallari. An application to operate a Adult Residential Facility (ARF) for (4) capacity, (0) ambulatory, (4) non-ambulatory, and (0) bedridden clients was received by Community Care Licensing (CCL) on 6/6/2023.

Structure: The facility is a one-story home with four client bedrooms, two bathrooms, living room, kitchen, dining room, two staff rooms, laundry room, storage room, an attached two car garage and backyard. The garage, storage room and staff rooms remain locked to restrict resident access. There is a back yard with two exit gates. There is one shaded seating area. Licensee stated they will be providing an additional table and chairs that have already been purchased. LPA did not observe any obstacles or hazards in the backyard.

Client Bedrooms: All client bedrooms have the required furnishings. LPA observed all resident beds have linens and blankets. LPA observed all windows were screened.

Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and are stored and locked in cabinets in the laundry room.

Medication, First Aid Kit and Files: All of these items will be locked in cabinets in the dining room

Smoke/CO2 Detectors & Fire Extinguisher: Dual smoke/CO2 detectors were tested and observed to be operational and connected. LPA observed the fire extinguisher to be fully charged with receipt indicating it was purchased on 10/05/2023.

Activity Materials: The facility has board games that are stored in the living room.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2023
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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LANCE CARE HOME
FACILITY NUMBER: 306006334
VISIT DATE: 11/08/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 05/01/2023.

Bathrooms: All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 109.8 degrees Fahrenheit in the bathroom accessible from the hallway and 109 degrees Fahrenheit in the bathroom accessible through bedroom 4.

Linens & Hygiene Supplies: A supply of extra linen and hygiene supplies is stored in a closet in the hallway.

Emergency Phone Numbers, Exit Plan & Menu: Posted and available for review

Food Service: There is a 7-day supply of non-perishable food on hand.

Appliances: Gas five burner stove/oven, refrigerator, dish washer, microwave, washer, and dryer are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2