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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006341
Report Date: 08/10/2023
Date Signed: 08/10/2023 03:32:27 PM

Document Has Been Signed on 08/10/2023 03:32 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PORTER RESIDENCES, THEFACILITY NUMBER:
306006341
ADMINISTRATOR:JABONERO, JEREMIASFACILITY TYPE:
735
ADDRESS:4237 W PORTER AVETELEPHONE:
(714) 975-3025
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 4CENSUS: DATE:
08/10/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jeremias Jabonero - AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility at 1:30pm and was greeted and granted entry by designated Administrator (AD) Jeremias Jabonero and Licensee Janice Jabonero. An application to operate an Adult Residential Facility (ARF) for (4) capacity, (4) ambulatory, (0) non-ambulatory, and (0) bedridden clients was received by Community Care Licensing (CCL) on 03/27/2023.

Structure:
The facility is a one-story home with four resident bedrooms, two full bathrooms, living room, kitchen, dining room, garage and backyard. The backyard has two shaded seating areas. LPA observed posted See Something, Say Something poster. There are two outdoor exit gates accessible on either side of the facility.

Client Bedrooms:
All resident bedrooms had the required furnishings. LPA observed all windows were screened

Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored in the garage in a locked cabinet.

Medications, First-Aid Kit & Book: Medication will be stored in a locked cabinet in the kitchen with the First Aid Kit and Book. The first aid kit has all the required elements.

Resident & Staff Files: Records will be kept in the medicine cabinet in the kitchen

Fire Extinguisher: LPA observed one fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone. LPA observed a service tag on the fire extinguisher which indicates the fire extinguisher was last serviced on 4/26/23.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PORTER RESIDENCES, THE
FACILITY NUMBER: 306006341
VISIT DATE: 08/10/2023
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Activity Materials: The facility has activity materials stored in the TV stand in the Living Room. Supplies include various games

Fire clearance: Was approved by a fire inspector of the Fullerton Fire Department on 4/24/2023.

Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements was give. A copy of the presentation was given to the facility.

Bathrooms: All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 116.3 degrees Fahrenheit in Bathroom 1. Hot water measured at 115.6 degrees Fahrenheit in Bathroom 2.

Linens & Hygiene Supplies: A supply of extra linen was stored in cabinets in the hallway. Hygiene supplies are store in a cabinet in the garage.

Emergency Phone Numbers & Exit Plan: Posted and available to view

Food Service & Menu: LPA observed the menu was posted and the facility has a 7-day supply of non-perishable food on hand.

Smoke Detectors: Smoke detectors were observed to be dual Smoke & Carbon Monoxide detectors that are stationed throughout the home. The dual detectors were tested and observed to be operational.

Appliances: Gas five burner stove with 1 oven, 1 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: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC809 (FAS) - (06/04)
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