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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006436
Report Date: 03/27/2024
Date Signed: 03/27/2024 12:55:18 PM

Document Has Been Signed on 03/27/2024 12:55 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:HOMEWOOD BOARD & CARE HOMEFACILITY NUMBER:
306006436
ADMINISTRATOR:HERNANDEZ, MARISAFACILITY TYPE:
735
ADDRESS:6382 HOMEWOOD AVE.TELEPHONE:
(714) 290-3809
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 4CENSUS: 0DATE:
03/27/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrators - Marisa Hernandez and Chris HanlyTIME COMPLETED:
01:10 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 Administrators Marisa Hernandez and Chris Hanly. An application to operate an Adult Residential Facility (ARF) for (4) capacity, (4) ambulatory, (0) non-ambulatory, and (0) bedridden clients was received by Community Care Licensing (CCL) on 10/16/2023.

The facility is a one-story home with four client bedrooms, two bathrooms, living room, dining room, kitchen, staff room, covered patio, laundry room and backyard. There is a large garage attached to the laundry room. This room is not included in the fire clearance and will remain locked and inaccessible to clients.

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. Hot water initially measured above 120 degrees Fahrenheit. AD adjusted the hot water heater during the inspection. LPA observed the hot water to be within the correct range during the inspection. LPA issued a technical assistance advising the AD to maintain a daily water log to ensure proper temperatures are maintained.

LPA observed the fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone.

Medications, First-Aid Kit, Resident & Staff Files will be locked in a lock box and shelving in the living room and cabinets in the kitchen.

The fire clearance was approved by a fire inspector of Orange County Fire Authority on 12/14/2023.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
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: HOMEWOOD BOARD & CARE HOME
FACILITY NUMBER: 306006436
VISIT DATE: 03/27/2024
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A supply of extra hygiene supplies and linens is stored in a closet in the hallway.

LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and are stored and locked in a lock box on the covered patio.

Emergency Phone Numbers, Exit Plan, Activity Calendar and Menu are all posted and available for review. LPA observed other necessary postings in the living room.

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, one refrigerators, dishwasher, microwave, washing machine and dryer.

LPA reviewed and provided Administrator 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: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC809 (FAS) - (06/04)
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