306006395-12-27-2023-22-AS-CGUZ-CYWRCY-20231227115507

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006395
Report Date: 12/27/2023
Date Signed: 12/27/2023 11:55:15 AM

Document Has Been Signed on 12/27/2023 11:55 AM - 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:	BAKER HOME		FACILITY NUMBER:	306006395
ADMINISTRATOR:	SAN DIEGO, CATHERINE		FACILITY TYPE:	735
ADDRESS:	624 W BAKER AVENUE		TELEPHONE:	(714) 270-9866
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92832
CAPACITY: 4		CENSUS: 0	DATE:	12/27/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Michael San Diego		TIME COMPLETED:	12:10 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) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with Licensee Michael San Diego. An application to operate an Adult Residential Facility (ARF) for (4) capacity, (4) ambulatory, (0) non-ambulatory, and (0) bedridden clients was received by CCL on 7/08/2023. Structure: The facility is a one-story house with four client bedrooms, two bathrooms, living room, kitchen, activity room, laundry room, and attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the activity room. There is a backyard with an exit gate each side of the house. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard. Resident Bedrooms All client bedrooms had the required furnishings. LPA observed all beds had linens and blankets. LPA observed all windows were screened. Signal system There is no signal system. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and will be stored and locked underneath the kitchen sink. Medications, First-Aid Kit & Book: Medication will be stored in a locked file cabinet. First aid kit is stored on top of medication cabinet. The first aid kit has all the required elements.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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: BAKER HOME	FACILITY NUMBER: 306006395
	VISIT DATE: 12/27/2023

NARRATIVE

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Resident & Staff Files:
Records will be kept locked in a locked file cabinet.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
Fire extinguisher is fully charged.

Reading Material, Games, Equipment & Materials:
The facility has card games, puzzles, and other recreational materials for the client’s use, stored in the activity room.

Fire clearance:
Was approved by a fire inspector of Fullerton Fire Department on 08/29/2023. Special conditions noted, “Built 1954. No sprinklers.”

Bedrooms Staff:
There is no staff bedroom.

Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured between 109.2 and 110.4 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available, means of exiting, and emergency phone numbers. Food menu is available for review in menu binder located in the kitchen.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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: BAKER HOME	FACILITY NUMBER: 306006395
	VISIT DATE: 12/27/2023

NARRATIVE

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Food Service:
A supply of 2-day perishable and 7-day of non-perishable food will be maintained on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas five burner stove with oven, refrigerator, dishwasher, microwave, washer, and dryer are operational.

Component III:

Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Licensee was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted and a copy of this report was provided to Licensee.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC809 (FAS) - (06/04)

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