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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006408
Report Date: 01/29/2024
Date Signed: 01/29/2024 03:14:37 PM

Document Has Been Signed on 01/29/2024 03:14 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:HAVEN OF HOPE CARE HOME LLCFACILITY NUMBER:
306006408
ADMINISTRATOR:DACAYO, ROSARIO RFACILITY TYPE:
735
ADDRESS:5040 SOMERSET STTELEPHONE:
(714) 300-9287
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 4CENSUS: 0DATE:
01/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Licensee - Rosario DacayoTIME COMPLETED:
03:30 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 and was greeted and granted entry by Licensee Rosario Dacayo. An application to operate an Adullt Residential Facility (ARF) for (4) capacity, (4) ambulatory, (0) non-ambulatory, and (0) bedridden clients was received by Community Care Licensing (CCL) on 08/25/2023.

The facility is a one-story home with four client bedrooms, three bathrooms, staff office, living room, dining room, kitchen, attached two car garage, covered patio and backyard. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entryway. There is a back yard with two exit gates. There is a covered patio with seating area in the backyard. LPA did not observe any obstructions blocking the exit gates or obstacles or hazards in the backyard.

Client Bedrooms have all the necessary requirements including bed, chair, storage for clothing and ample lighting. LPA observed all windows were screened.

All bathrooms have working plumbing and designated hand washing posters. In the master bathroom, hot water measured at 110.4 degrees Fahrenheit. In the bathroom nearest to Room 2, hot water measured at 111 degrees Fahrenheit. In the bathroom nearest to the kitchen, hot water measured at 115 degrees Fahrenheit.

LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and are stored and locked in a cabinet in the kitchen and in a closet in the living room.

Medications, First-Aid Kit, Resident & Staff Files will be locked in cabinets in the dining room.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HAVEN OF HOPE CARE HOME LLC
FACILITY NUMBER: 306006408
VISIT DATE: 01/29/2024
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LPA observed the fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone. LPA observed a service tag for the fire extinguisher which indicates the it was last serviced on 9/12/2023

The facility has a sample activity calendar with activities including but not limited to board games, karaoke, walks, arts and crafts and exercise.

The fire clearance was approved by a fire inspector of Orange County Fire Authority on 9/20/2023.

A supply of extra linens is stored in the closet near Room 2.

Emergency Phone Numbers, Exit Plan & Menu are all posted and available for review.

There is a 7-day supply of non-perishable food on hand.

Smoke and Carbon Monoxide detectors are stationed throughout the home and are wired together. Both types of detectors were tested and noted as operational.

Operational appliances include a gas stove, oven, refrigerator, dishwasher, microwave, washing machine and dryer.

LPA reviewed and provided Licensee with the Component III presentation to offer information and resources regarding maintaining facility compliance.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024
LIC809 (FAS) - (06/04)
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