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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006378
Report Date: 10/12/2023
Date Signed: 10/12/2023 03:16:20 PM

Document Has Been Signed on 10/12/2023 03:16 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:LANTANA HOMEFACILITY NUMBER:
306006378
ADMINISTRATOR:SHARMA, NARESHFACILITY TYPE:
735
ADDRESS:7704 LANTANA DRTELEPHONE:
(714) 858-2351
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 4CENSUS: DATE:
10/12/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Naresh Sharma - AdministratorTIME COMPLETED:
03:35 PM
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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 1:20 pm and was greeted and granted entry by designated Administrator (AD) Naresh Sharma. 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 7/3/2023.

Structure: The facility is a one-story home with four resident bedrooms, two bathrooms, living room, kitchen, dining room, backyard and detached two car garage. There is one exit gate in the back yard. Based on review of facility sketch, LPA noted that there are no arrows pointing to the backyard exit gate. Administrator stated they will update the facility sketch to show the exit path in the backyard and email the updated sketch to LPA and CAB Analyst. The facility has patio chairs but no table. LPA also observed the following items in the backyard: a pile of cardboard boxes next to one of the bushes, a doghouse with chipped paint and warped wood, a crate of unused bathroom tiles, a rusted paint can, unused trash cans and bags of fertilizer that have been ripped open. AD stated the facility has no immediate plans to get a dog.

Client Bedrooms: All resident bedrooms had the necessary furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened.

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

Medications, First-Aid Kit & Files: Medication will be stored in a locked cabinet in the hallway. First Aid Kits will be stored with medication and in the kitchen. Records will be kept in a cabinet beneath the medication.

Fire Extinguisher: LPA observed fire extinguisher to be fully charged
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2023
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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