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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006491
Report Date: 09/30/2024
Date Signed: 09/30/2024 03:20:43 PM

Document Has Been Signed on 09/30/2024 03:20 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:STANTON BOARD AND CARE HOMEFACILITY NUMBER:
306006491
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, GREGFACILITY TYPE:
735
ADDRESS:8296 STANTON AVENUETELEPHONE:
(714) 816-5043
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 4DATE:
09/30/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Diana Hernandez & Arianna HernandezTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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Licensing Program Analysts (LPA) Jerome Haley made an announced visit for the purpose of conducting a pre-licensing evaluation. LPA Haley was greeted and granted entry by applicant by staff. During the inspection, LPA Haley met with applicants Diana Hernandez, Greg Hernandez and Arianna Hernandez.

Initial application: To operate an Adult Residential Care Facility, with a capacity of 6 ambulatory clients was submitted to the department for licensure.



Fire clearance: Orange County Fire Authority granted the Fire Clearance April 2, 2024

Structure:
The facility is a single level structure, with an attached garage that has been converted to an office area. There’s a total of 6 bedrooms, 4 of which will be used for clients and 2 bedrooms will be designated for staff. There’s one living room space, one dining room, and one office area. Bedrooms (Clients): All bedrooms have the required furnishings: bed, lamp, chair, and storage space. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. Grab bars were tightly secured. Hot Water Temperature in Bathroom #1 was measured at 113.4 degrees Fahrenheit and 105.8 degrees Fahrenheit in bathroom #2. Kitchen: The gas stove was operational, and all burners were in good working order. Food Service: A food supply that meets regulation requirements was observed in the refrigerator. A non-perishable food supply that meets regulation requirements was observed in the pantry, and a sample menu was observed on the side of the refrigerator. Office Area: The garage has been converted into an office area. Staff and client files are stored in the office area which remains locked. An additional supply of non-perishable food items. There's an extra refrigerator used to store an additional food supply. Hazardous cleaning chemicals are stored in the locked office area. First aid supplies including first aid manuals were observed in a locked filing cabinet. An emergency supply of food items and emergency supply of water was observed. Laundry: There's a dryer in the garage and a washer in the kitchen.
Continued on LIC809C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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 2
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: STANTON BOARD AND CARE HOME
FACILITY NUMBER: 306006491
VISIT DATE: 09/30/2024
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Client & Staff Files: Client and staff files are stored in the office area and kept in locked filing cabinets.

Medications/First-Aid Kit: Medications are kept in a locked toolbox that’s stored in a caregiver’s room that remains locked. First aid kits are stored in the office area in a filing cabinet. Knives and sharp objects are also locked in a toolbox in the staff room which remains locked.

Linens & Hygiene Supplies: Adequate supply of linen was stored in cabinets in the hallway. An additional supply of hygiene supplies are stored in the office area. Daily Hygiene items are kept in the client bedrooms.

Toxins: All toxic chemicals and cleaning solutions are inaccessible to clients and are stored in a locked toolbox that’s stored right outside the kitchen in the backyard.

Backyard/Exterior:
There is a large backyard with large exit gate. A shaded patio area with a table and chairs was observed. All walkways were clear and free of obstruction.

Bodies of Water: No bodies of water were observed.

Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational. A carbon monoxide detector was observed plugged in the wall in the hallway.

Emergency Phone Numbers, House Rules, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan, a list of emergency phone numbers, house rules on the facility postings board in the living room area, and a sample menu posted in the kitchen.

Fire Extinguisher: Observed full charged mounted in the kitchen on the wall above the washing machine. Another fire extinguisher was observed in the living room near the facility postings board.

Component III: Will be waived as the facility is currently licensed.

No corrections are needed. No deficiencies were observed. The facility is ready for licensure.
An exit interview was conducted, and a copy of this report was provided to applicant Diana Hernandez.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
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