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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006408
Report Date: 01/21/2025
Date Signed: 01/21/2025 02:50:25 PM

Document Has Been Signed on 01/21/2025 02:50 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:HAVEN OF HOPE CARE HOME LLCFACILITY NUMBER:
306006408
ADMINISTRATOR/
DIRECTOR:		DACAYO, ROSARIO RFACILITY TYPE:
735
ADDRESS:5040 SOMERSET STTELEPHONE:
(714) 300-9287
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 4CENSUS: 3DATE:
01/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:28 PM
MET WITH:Marieta ManaloTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On January 21st, 2025 Licensing Program Analyst (LPA) William Vanegas made an unannounced visit for the purposes of an annual inspection. Upon arrival LPA Vanegas was greeted and granted entry by Care Giver (CG) Nestor Manalo. LPA Vanegas began a tour of the facility and observed the following.

This is a one storied home with five bedrooms, one of which is a staff bedroom, and four of which are client bedrooms. There are three bathrooms for client use, and an attached two car garage. LPA Vanegas observed the kitchen to be clean and sanitary, LPA Vanegas observed a gas stove, microwave, dishwasher, refrigerator, and a washer and dryer to all be in good repair and functional. LPA Vanegas observed a two day supply of perishable food, and a seven day supply of non-perishable food, and a sufficient amount of emergency water on hand.

LPA Vanegas observed fire extinguisher to be fully charged and up to date. LPA Vanegas observed smoke and carbon monoxide detectors to be in good repair and functional. LPA Vanegas observed all client rooms to have the required furnishings such as a lamp, chest of drawers, a chair, a bed, enough storage space for personal items, and linens that are in good repair meaning no strains or tears.

LPA Vanegas observed resident bathrooms to be clean and sanitary and free of mildew and debris. Toilet and water faucet tested operational, and water tested between 113.2 and 115.1 Degrees. LPA Vanegas observed outside of the facility to be clean and free of debris along the emergency exit routes. There is an outdoor shaded seating area and it is big enough to participate in outdoor activities.

LPA Vanegas observed garage to be clean and contains emergency food and water.
CONTINUED ON LIC809C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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 3
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: HAVEN OF HOPE CARE HOME LLC
FACILITY NUMBER: 306006408
VISIT DATE: 01/21/2025
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LPA Vanegas reviewed infection control plan and emergency disaster plan, and all items were up to date and reviewed LPA Vanegas reviewed medications with administrator (AD) Rosario Dacayo. Per LPA Vanegas review medications are being administered per physicians orders. LPA Vanegas reviewed P&I with AD and per LPA Vanegas review, all balances and documentation are accurate and up to date.

LPA Vanegas reviewed three staff files and three client files staff files contained all required documentation. two of three client files did not contain all required documents due to being new to the facility and a technical violation was issued on today's date.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC809 (FAS) - (06/04)
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