306006464-5-20-2025-22-AS-WVAS-DGUVBK-20250520161740

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006464
Report Date: 05/20/2025
Date Signed: 05/20/2025 04:18:03 PM

Document Has Been Signed on 05/20/2025 04:18 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:	SOMERSET HOME 4		FACILITY NUMBER:	306006464
ADMINISTRATOR/ DIRECTOR:	BELEN, LENETTE L.		FACILITY TYPE:	735
ADDRESS:	1668 W PALAIS ROAD		TELEPHONE:	(714) 814-8149
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92802
CAPACITY: 4		CENSUS: 4	DATE:	05/20/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:45 PM
MET WITH:	Alma Encelan Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) William Vanegas conducted an unannounced inspection for the purposes of completing an annual inspection. Upon arrival LPA Vanegas was greeted and granted entry to the facility by Direct Support Staff (DSP) Anarosa Magno. LPA explained the purpose of the inspection, and 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 room, and four of which are client rooms. There is an attached one car garage, and two bathrooms one of which is a private bathroom in the staff room, and one that is a shared bathroom. LPA Vanegas observed the kitchen area to be clean and free of debris. LPA Vanegas observed a refrigerator, dishwasher, microwave, gas stove, washer, and dryer all to be in good repair and in working condition. LPA Vanegas observed a seven day supply of non-perishable food, and a two supply of perishable food. LPA Vanegas observed a sufficient amount of emergency water on hand as well. LPA Vanegas observed all restrooms to be clean and free of debris and mildew. LPA Vanegas observed the sinks and toilets to be operational. The bathrooms had all required furnishings such as grab bars, and slip resistant floor matts. Bathroom water tested between 115.7 and 116.7 degrees. CONTINUED ON LIC809C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: SOMERSET HOME 4	FACILITY NUMBER: 306006464
	VISIT DATE: 05/20/2025

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LPA Vanegas observed all rooms to have required furnishings such as chest drawers, a chair, a lamp, enough storage space to store personal belongings, a bed, clean linens in good repair; meaning no strains or tears. The rooms were observed to be large enough to walk about freely, and no obstructions were noted blocking the entry way.

LPA Vanegas observed the outside of the facility to be clean, and free of any debris. LPA Vanegas observed the backyard to be large enough to participate in outdoor activities upon client request. There is an outdoor shaded sitting area, and the exit routes were observed to have no obstructions along the path. Side gates are self latching an unlocked.

LPA Vanegas observed all fire extinguishers to be fully charged and up to date. LPA Vanegas observed all smoke and carbon monoxide detectors to be in good repair and tested operational. LPA Vanegas observed first aid kit to contain all required items including bandages, adhesive tape, tweezers, scissors, and a thermometer.

LPA Vanegas reviewed medications to be documented correctly, and per LPA review all medications are being given to clients in care per physicians orders. LPA Vanegas reviewed three staff files, and four client files. All files (Staff and Client) had all required documents. LPA Vanegas reviewed P&I with Administrator Alma Encelan and all balances were accounted for, and documented correctly.

Based on observations made during today's inspection no deficiencies will be issued per title 22 chapter 8 division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Alma Encelan, and a copy of this report was provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

LIC809 (FAS) - (06/04)

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