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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006396
Report Date: 01/06/2025
Date Signed: 01/06/2025 06:10:58 PM

Document Has Been Signed on 01/06/2025 06:10 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:IMMANUEL CARE HOME LLCFACILITY NUMBER:
306006396
ADMINISTRATOR/
DIRECTOR:		BOTIN, JOAN CHRISTINEFACILITY TYPE:
735
ADDRESS:7949 LA CORONA WAYTELEPHONE:
(562) 219-9922
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 4CENSUS: 3DATE:
01/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Joan Christine BotinTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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On January 6, 2025 at 10:00am, Licensing Program Analyst (LPA) Eboni Bentley made an unannounced visit for the purpose of conducting a required one-year annual inspection using the CARE Inspection Tool. LPA Bentley was greeted, granted entry by Caregiver (CG) Granville Piso and explained the reason for the visit. CG Piso called Licensee (LI) Joan Christine Botin by telephone, who arrived a short time later and was present for the visit. LI Botin has a current Administrator certificate with an expiration date of November 16, 2025.

The facility is a one-level structure licensed for four (4) ambulatory clients, age 18 through 59 and offers Adult Residential Care. This is a four bedroom and two bathroom home in a residential neighborhood. There were three clients present for today's visit. LPA Bentley conducted a tour of the physical plant accompanied by LI Botin and the following was observed: There were no bodies of water on the premises, all rooms were inspected, beds and bedding supplies were available, lighting was provided in all rooms, and storage for the client's personal belongings was observed in clients’ closets. Bathrooms were operational with water temperatures measured temperature range of 105.4 degrees F and 105.6 degrees F. Smoke and carbon monoxide detectors were tested and operational.

All client bedrooms were clean, well-organized, and had all the necessary items and storage space. The kitchen was clean and organized. All knives and hazardous cleaning chemicals were found in a locked cabinet. A two-day supply of perishable food items and seven-day supply of nonperishable food items was observe.

The garage was clean organized, and walkways were free of clutter and debris. A refrigerator with a supply of perishable items and a washer and dryer were observed to be in working condition. LPA Bentley observed a first aid kit with all the required elements were present. Facility has emergency food and water supply. A review of the Medication and Medication Administration Record (MAR) was conducted, and LPA Bentley observed the records are in compliance.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025
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 5
Document Has Been Signed on 01/06/2025 06:10 PM - It Cannot Be Edited


Created By: Eboni Bentley On 01/06/2025 at 05:13 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: IMMANUEL CARE HOME LLC
FACILITY NUMBER: 306006396

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in one out of two background clearances. Based on documents, S1 was background cleared but not associated to this facility, which poses a potential safety risk to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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Licensee stated they will associate S1 immediately and ensure all staff are background cleared and associated and submit proof to CCLD via email to eboni.bentley@dss.ca.gov by POC due date stated above.
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Eboni Bentley
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/06/2025 06:10 PM - It Cannot Be Edited


Created By: Eboni Bentley On 01/06/2025 at 05:13 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: IMMANUEL CARE HOME LLC
FACILITY NUMBER: 306006396

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
Personnel Records
(e) All personnel records shall be maintained at the facility site.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff interview and record review, the licensee did not comply with the section cited above as a personnel record is not currently being maintained on licensee or staff, which poses a potential health and personal rights risk to persons
in care.
POC Due Date: 01/14/2025
Plan of Correction
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Licensee stated a personnel record will be maintained for Licensee and staff and submit proof to CCLD via email to eboni.bentley@dss.ca.gov by POC due date stated above.
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Eboni Bentley
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: IMMANUEL CARE HOME LLC
FACILITY NUMBER: 306006396
VISIT DATE: 01/06/2025
NARRATIVE
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The backyard was clean and free of clutter and debris. A shaded patio area with tables and chairs observed.
A review of three (3) clients service files revealed to be complete. Facility has liability insurance on file effective July 24, 2024 through July 24, 2025. The facility has the current administrator's certification on file for Joan Christine Botin with an expiration date of November 11, 2025.

Deficiencies were cited during today’s inspection visit.

An exit interview conducted and a copy of the report and appeal rights were provided to Licensee Joan Christine Botin.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
LIC809 (FAS) - (06/04)
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