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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006363
Report Date: 12/17/2024
Date Signed: 12/17/2024 02:49:11 PM

Document Has Been Signed on 12/17/2024 02:49 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:QUEENS HOME 3FACILITY NUMBER:
306006363
ADMINISTRATOR/
DIRECTOR:
MAGHBOULEH, KATHYFACILITY TYPE:
740
ADDRESS:14752 HOLT AVETELEPHONE:
(714) 731-6385
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 15CENSUS: DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Arya MaghboulehTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA Samer Haddadin made an announced visit to the facility for purpose of conducting a required annual inspection. LPA arrived at the facility and was greeted and granted entry by Administrator AD Kathy Maghbouleh.
The facility is a two-unit one-story house each as unit A and Unit B. Unit A has 4 resident bedrooms, 1 staff bedroom, 2 full bathrooms, a living room, a dining room, and a kitchen. Unit B has 6 resident bedrooms, 1 staff bedroom, 3 full bathrooms, a living room, a dining room, and a kitchen. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with an exit walkway on one side of the house with 2 covered seating patios for the residents.
Facility appears clean, safe, and sanitary. All residents’ rooms had required elements, including bed, chair, closet space, and ample lighting. Facility had extra linens and hygiene supplies for residents in care. Restrooms were stocked with soap and paper towels. Hot water measured at 115.6 degrees Fahrenheit in all bathrooms. LPAs observed the facility had a two-day supply of perishables and a seven-day supply of non-perishable food. LPAs observed hallways and walkways were free of obstruction.

LPAs observed the fire extinguisher was charged based on the arrow on the extinguisher's meter pointing into the green zone. The service tag indicates the extinguisher was last serviced on November 27, 2024. LPA tested smoke and carbon monoxide detectors LPAs observed the detectors to be operational.

Chemicals and toxins are locked up in the kitchen closet. LPAs noted the facility's knives and sharps are in the kitchen secured and locked. Medication for each resident is kept locked in the staff office as well as staff and residents files. The backyard has one shaded seating area, and the exit gate is unlocked and unobstructed. No bodies of water observed.

No deficiencies were noted during today's inspection visit. An exit interview was conducted, and a copy of this report was provided to the facility staff.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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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