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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006378
Report Date: 10/02/2024
Date Signed: 10/02/2024 05:18:52 PM

Document Has Been Signed on 10/02/2024 05:18 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:LANTANA HOMEFACILITY NUMBER:
306006378
ADMINISTRATOR/
DIRECTOR:		SHARMA, NARESHFACILITY TYPE:
735
ADDRESS:7704 LANTANA DRTELEPHONE:
(714) 858-2351
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 4CENSUS: 3DATE:
10/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:48 PM
MET WITH:Naresh Sharma- AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1 Year evaluation using the Care Inspection Tool. LPA was greeted and granted entry by Care Staff Hassan Muhidin after explaining the reason for the visit. Administrator (Admin) Naresh Sharma arrived shortly.

The facility is a single story home located in a residential neighborhood. Facility offers at a Service level 4A and is licensed to serve four (4) ambulatory clients. The client census is three and one staff are on duty in addition to the administrator.

LPA conducted the tour of the physical plant accompanied by Admin Sharma. Facility consists of three client bedrooms and one client bathroom. There is one private bedroom and bathroom for the staff. The private bathroom is also utilized by the clients as needed. LPA observed the facility to in good repair, however areas of the facility required deep cleaning such as the kitchen appliances/drawers, bathrooms, and flooring throughout the facility. The common areas were inspected including the detached two car garage which is utilized as storage/laundry room. LPA observed clutter from the ceiling to the ground. The clients' bedrooms were appropriately furnished. Beds and bedding supplies were in good condition, adequate lighting was provided, sufficient storage space for personal belongings were observed. Bathrooms were found to be operational, however requires a deep cleaning. The water temperature measured at 108.3 and 108.6 degrees Fahrenheit. The indoor temperature was within a comfortable range. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed adequate supply of two day perishables and seven day non-perishable food. LPA toured the outside grounds. LPA observed the outdoor passageway free of obstruction. The exit gate was operational. LPA observed sufficient seating and shading in the back yard. Facility maintains a fire extinguisher which was purchased on July 18, 2024. The smoke/carbon monoxide detectors were tested and operational.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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 4
Document Has Been Signed on 10/02/2024 05:18 PM - It Cannot Be Edited


Created By: Jessica Cho On 10/02/2024 at 04:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LANTANA HOME
FACILITY NUMBER: 306006378

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, there was clutter in the garage, bathrooms, kitchen, and the flooring was not clean and sanitary which poses a potential Health, Safety, or Personal Rights risk to persons in care.
POC Due Date: 10/23/2024
Plan of Correction
1
2
3
4
Administrator stated that the items above will be corrected by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lourdes Montoya
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LANTANA HOME
FACILITY NUMBER: 306006378
VISIT DATE: 10/02/2024
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
LPA observed the emergency disaster supplies including food/water. Each client is assigned to an emergency back pack. Emergency evacuation drills are conducted evidenced by the emergency logs. A working facility cell phone, (714) 801-3330, remains available.

During today's visit, LPA conducted an audit of three client files and one personnel file. No discrepancies noted. Medications were audited for three clients. No discrepancies noted. The Personal & Incidental (P&I) Funds were audited. No discrepancies noted. Interviews were conducted with one staff. No interviews conducted with the clients.

The administrator was advised on the following: to clean/organize the clutter in the garage, vacuum the food particles on the sofa, deep clean the kitchen appliances internally/externally including the kitchen drawers/counter top, deep clean the bathrooms and the flooring throughout the facility, remove two wasp nests by the front door, and to update the infection control plan.

Based on the observations made during today's visit, a deficiency is being cited. Technical Advisories (LIC9102) are being issued.

An exit interview was conducted with Administrator Naresh Sharma, and a copy of this report along with the LIC9099-C, LIC9099D, LIC9102s, and the appeal rights were provided at the end of the visit.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4