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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006488
Report Date: 10/04/2024
Date Signed: 10/04/2024 11:27:03 AM

Document Has Been Signed on 10/04/2024 11:27 AM - 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:PACIFIC BOARD AND CARE HOMEFACILITY NUMBER:
306006488
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, DIANAFACILITY TYPE:
735
ADDRESS:7612 PACIFIC AVENUETELEPHONE:
(714) 266-0194
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 6CENSUS: 6DATE:
10/04/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:36 AM
MET WITH:Diana Hernandez - AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:42 AM
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Licensing Program Analysts (LPAs) Dwayne Mason Jr. and William Vanegas made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPAs arrived at the facility and were greeted and granted entry by designated Administrator (AD) Diana Hernandez. An application to operate a Adult Residential Facility (ARF) for (6) capacity, (6) ambulatory, (0) non-ambulatory, and (0) bedridden clients was received by CCL on 1/2/2024.

The facility is a one-story home with four client bedrooms, three client bathrooms, living room, den, kitchen, dining room, caregiver room, relief room, office, backyard and an attached two car garage. There is a back yard with an exit gate on each side of the house. There is a shaded seating area in the backyard. LPAs did not observe any obstacles or hazards in the backyard.



All client bedrooms had the required furnishings and ample lighting. LPAs observed all client beds had linens and blankets. LPAs observed all windows were screened.

All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked outside near the laundry machines.

Medication, First Aid Kit and Manual are stored in a locked closet in the hallway. The first aid kit has all the required elements.

Client & Staff Records are kept locked in the office. LPAs reviewed three out of six client files and two staff files. Each contained the required elements.

All fire extinguishers are fully charged and were last purchased within the last year.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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: PACIFIC BOARD AND CARE HOME
FACILITY NUMBER: 306006488
VISIT DATE: 10/04/2024
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SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
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: PACIFIC BOARD AND CARE HOME
FACILITY NUMBER: 306006488
VISIT DATE: 10/04/2024
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The facility has board games, playing cards, puzzles and clients have personal electronic devices. The clients also go on outings.

Fire clearance was approved by a fire inspector of Orange County Fire Authority on 4/2/2024.

Component III was conducted at a previous Pre-Licensing visit. LPAs provided PDF version of presentation. One bedroom will be occupied by staff. There is one overnight staff each night.
All bathrooms have working plumbing and designated hand washing posters. Hot water measured between 105-120 degrees Fahrenheit in the two client bathrooms. Client bathrooms also have shower mats in all showers.

A supply of extra linen is stored in the hallway closets/cabinets.

Emergency Phone Numbers, Exit Plan, Activity Calendar & Menu are posted and available for review
There is a supply of 2-day perishable and 7-day of non-perishable food on hand. Smoke detectors and Smoke/Carbon monoxide detectors tested operational.
Gas stove, oven, refrigerators/freezers, dish washer, microwave, washer and dryer are operational.

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 and the Component III presentation was provided to designated AD.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
LIC809 (FAS) - (06/04)
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