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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006347
Report Date: 05/31/2023
Date Signed: 05/31/2023 04:22:08 PM

Document Has Been Signed on 05/31/2023 04:22 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:CAMBRIDGE MENTAL HEALTH MANAGEMENT, LLCFACILITY NUMBER:
306006347
ADMINISTRATOR:KUMAR, NEHAFACILITY TYPE:
772
ADDRESS:19402 SIERRA BELLO RDTELEPHONE:
(562) 519-1700
CITY:IRVINESTATE: CAZIP CODE:
92603
CAPACITY: 6CENSUS: 0DATE:
05/31/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Neha KumarTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Lydia Martinez made an announced visit for the purpose of conducting a Pre-Licensing evaluation. LPA Martinez met with Program Director/Administrator Neha Kumar; Operations Manager, William Lemme; Quality Assurance and Compliance Manager, Whitney Buss; and Administrative Assistant, Christiana Castanon. A Change of Location application to operate a Social Rehabilitation Facility was received by the Central Applications Bureau (CAB) on 04/24/2023 for a capacity of 6 ambulatory clients.

LPA Martinez along with Staff above toured the facility and observed the following:
Structure:
Facility is a two story house with a total of 4 client bedrooms, 5.5 bathrooms, a Therapy room, Living room, Dining room, Kitchen, Nursing station, Laundry room and TV/Loft room. There is an attached 2 car garage. The backyard has a seating area with huge umbrellas for clients and visitors. Facility has video surveillance cameras installed in common areas.
Signal System:
The facility has central heating and air conditioning.
Bedrooms Clients:
Bedrooms accommodate ambulatory clients. The client bedrooms accommodate the required clients' furnishings such a bed, chair, dresser, night stand and lighting.
Bathrooms:
Bathrooms have a working toilet, shower and wash basin. A non-skid surface was present in each shower.
Linens and Hygiene Supplies:
Adequate supply of linens and client hygiene supplies are stored in hallway closets.
Emergency Phone Numbers, Exit Plan:
Readily available for review with a facility sketch and exit plan posted in the entry of the facility.
Postings:
Client Rights postings were observed throughout the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023
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: CAMBRIDGE MENTAL HEALTH MANAGEMENT, LLC
FACILITY NUMBER: 306006347
VISIT DATE: 05/31/2023
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Food Service and Menu:
There will be an adequate supply of 7 day non-perishable and 2 day perishables present in the facility. LPA reminded the facility that dated menus as served must be kept in the facility. Additional food and emergency supplies were stored in plastic bins located in the garage.
Smoke and Carbon Monoxide Detectors:
Smoke and carbon monoxide detector alert systems are hardwired.
Fire Extinguisher:
Fire Extinguishers were located throughout the facility both downstairs and upstairs. They were fully charged and mounted on facility walls. The fire extinguishers were last serviced on 05/02/2023.
Fire Clearance:
Approved on 05/22/2023 for 6 ambulatory clients.
Appliances:
Gas six burner stove with overhead fan and light, 2 single ovens, refrigerator/freezer, microwave, and two dishwashers, all are clean and noted to be operational. The washer and dryer are located in the laundry room upstairs and noted to be in operating condition.
Toxins and Sharps:
Locked and stored in a locked hallway closet. The knives and other sharp items will be stored in a locked hallway closet
Water Temperature:
Hot water is within regulatory requirements.
Medications, First Aid Kit & Manual:
The facility had multiple First Aid kits with manuals located throughout the facility. Client medication will be stored in locked Nurses Station.
Client and Staff Files:
Client and staff records will be in an electronic format stored on a computer located in Nurses Station.
Reading Material, Games, Equipment, & Materials:
Facility has sufficient reading materials, and board games.
Component III:
Component III Orientation is not required as this is a change of location of an existing Facility.

Facility appears to be in compliance and ready to be licensed. 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: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023
LIC809 (FAS) - (06/04)
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