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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006493
Report Date: 07/02/2024
Date Signed: 07/02/2024 03:51:10 PM

Document Has Been Signed on 07/02/2024 03:51 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:CLAIRE HOUSE, THEFACILITY NUMBER:
306006493
ADMINISTRATOR/
DIRECTOR:
ROBERTSON, MILES ANTHONYFACILITY TYPE:
735
ADDRESS:5672 SAINT ANN AVETELEPHONE:
(714) 209-5256
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY: 4CENSUS: 0DATE:
07/02/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Juliana & Tusitino Sauvao, LicenseesTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPA met with Licensees Juliana and Tusitino Sauvao. An application to operate an Adult Residential Facility Level 4i was received by our agency on February 29, 2024 for a total capacity of four ambulatory clients.

The facility is a one story home with four client bedrooms, two bathrooms, a living room, a kitchen/dining area, and an unattached two car garage. All exiting doors had alarm notifications. There is a backyard exit gate on the side of the house that is self-latching and unlocked. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard. LPA conducted testing of hot water temperature in two of two client bathrooms. The hot water temperature measured between 118.4 and 120.0 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on April 4, 2024. LPA observed the See Something, Say Something poster (PUB 475), Personal Rights, Visiting Hours and Emergency Disaster Plan in the facility mounted on the wall in the living room area. Client bedrooms had the required furnishings. LPA observed all beds had linens and blankets. All toxic chemicals, cleaning solutions, and disinfectants are inaccessible to clients and will be stored and locked in the garage. Medications will be stored in a locked cabinet. The first aid kit is stored in the cabinet and has all the required elements. Reading materials, sensory items, puzzles and board games were observed in the living room with a phone for client use. A supply of two-day perishables and seven-day of non-perishable food was observed and will be maintained on hand. Gas burner stove, dishwasher, refrigerator, microwave, washer, and dryer are operational.

LPA conducted the Component Three Orientation with Licensees and the licensees were notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted and a copy of this report was provided to Licensees.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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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