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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006395
Report Date: 01/13/2025
Date Signed: 01/13/2025 11:40:38 AM

Document Has Been Signed on 01/13/2025 11:40 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BAKER HOMEFACILITY NUMBER:
306006395
ADMINISTRATOR/
DIRECTOR:		SAN DIEGO, CATHERINEFACILITY TYPE:
735
ADDRESS:624 W BAKER AVENUETELEPHONE:
(714) 270-9866
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 4CENSUS: 2DATE:
01/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Michael San DiegoTIME VISIT/
INSPECTION COMPLETED:
11:54 AM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator Michael San Diego and explained the reason for the visit. The Administrator's certificate expires on October 6, 2025. The facility is licensed for 4 ambulatory clients. Facility is a single story home with 4 bedrooms, 2 bathrooms, living room, kitchen, laundry room, 2 car garage and activity room. LPA and Administrator toured the facility. LPA observed the kitchen is clean and organized. The gas stove lights unassisted. The knives are kept locked under the kitchen sink along with cleaning supplies. Medication is kept locked in a file cabinet. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the laundry room has a 3 day supply of emergency food and water. The garage is kept locked and used for storage. LPA observed a TV in the living room. There are games and puzzles in the activity room. LPA observed all client bedrooms have the required furnishings. Smoke detectors/carbon monoxide detector tested operational. LPA observed all 3 fire extinguishers are fully charged. LPA observed both bathrooms are clean and operational. LPA observed bathroom 1's window is missing a screen. Hot water measured 125.0 degrees Fahrenheit in both bathrooms. The last fire drill was conducted on December 28, 2024. LPA and Administrator toured the backyard. No bodies of water observed. Both exit gates are operational. There is a table with an umbrella and chairs to sit outside. No obstacles or hazards observed in the backyard. LPA reviewed 2 staff files. No discrepancies observed. Both staff members have current CPR/First Aid training. All staff are background cleared and associated to the facility. LPA reviewed 4 client files and medication. No discrepancies observed. LPA reviewed client P & I monies, no discrepancies observed. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2025
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 01/13/2025 11:40 AM - It Cannot Be Edited


Created By: Joseph Alejandre On 01/13/2025 at 11:28 AM
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: BAKER HOME
FACILITY NUMBER: 306006395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, LPA measured the hot water in both bathrooms at 125.0 degrees Fahrenheit which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/14/2025
Plan of Correction
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LIcensee agrees to adjust the hot water tempterature so it measures 105.0 to 120.0 degrees Fahrenheit in both bathrooms.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2025


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/13/2025 11:40 AM - It Cannot Be Edited


Created By: Joseph Alejandre On 01/13/2025 at 11:28 AM
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: BAKER HOME
FACILITY NUMBER: 306006395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, LPA observed there was no window screen in bathroom 1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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Licensee agrees to have a new window screen installed in bathroom 1's window.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2025


LIC809 (FAS) - (06/04)
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