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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006509
Report Date: 12/13/2024
Date Signed: 12/13/2024 03:47:10 PM

Document Has Been Signed on 12/13/2024 03:47 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:MENTAL HEALTH HOUSE, LLCFACILITY NUMBER:
306006509
ADMINISTRATOR/
DIRECTOR:		DYAR, COLEFACILITY TYPE:
772
ADDRESS:13871 GLENMERE DRIVETELEPHONE:
(559) 303-8854
CITY:NORTH TUSTINSTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 5DATE:
12/13/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Cole Dyar-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:07 PM
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Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Brandon Lopez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPAs met with Administrator (AD) Cole Dyar.

An application for a Change of Ownership (CHOW) to operate a Social Rehabilitation Facility (SRF) for a capacity of (6), (6) ambulatory, (0) non-ambulatory, and (0) bedridden clients was received by Community Care Licensing on June 12, 2024. Facility phone number 559-303-8854 LPAs observed the following.



Structure:
The facility is a two-story house with four client bedrooms, four bathrooms, living room, kitchen, dining area, laundry room, staff office and attached three car garage. LPAs observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall by the entranceway. There is a backyard with an exit gate on each side of the house. There is a shaded seating area and LPAs did not observe any obstacles or hazards in the backyard.

Resident Bedrooms
All resident bedrooms had the required furnishings. LPAs observed all beds had linens and blankets.

Signal system
There is no signal system.



CONTINUED ON LIC9099-C...
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2024
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 3
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: MENTAL HEALTH HOUSE, LLC
FACILITY NUMBER: 306006509
VISIT DATE: 12/13/2024
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Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked in the garage.

Medications, First-Aid Kit & Book:
Medication is stored in a locked staff office in a locked medicine cart. First aid kit is stored in the medication room. The first aid kit has all the required elements.

Resident & Staff Files:
Records will be kept locked in a staff office.

Pool/Jacuzzi:
Pool and jacuzzi in the back courtyard were observed to be fenced by a 5 feet fence.


Fire Extinguisher:
One fire extinguisher is located by the kitchen and one in the second floor. Fire extinguishers were fully charged with service tags dated October 10, 2024.

Reading Material, Games, Equipment & Materials:
The facility has reading books, arts and crafts supplies, cards/board games, puzzles, and other recreational materials for client use stored in a cabinet by the dining room.

Bedrooms Staff:
There is no staff bedroom.

Bathrooms:
All bathrooms have working plumbing. Hot water measured between 109.7-113.5 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in a closet in the laundry room and in the staff office.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: MENTAL HEALTH HOUSE, LLC
FACILITY NUMBER: 306006509
VISIT DATE: 12/13/2024
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Emergency Phone Numbers, Exit Plan & Menu:
Posted and available for review, an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was also posted and available.

Food Service:
A supply of 2-day perishable and 7-day of non-perishable food was observed and will be maintained on hand.

Smoke Detectors:
Carbon monoxide and smoke detectors tested operational.

Appliances:
Gas burner stove, refrigerator, microwave, washer, and dryer were inspected and observed to be operational.

Fire clearance:


Fire Clearance approved by the Orange County Fire Authority on February 28, 2024. Special conditions noted: None.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

LPAs advised Applicant to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for inquiries and to submit incident reports.

The applicant has met all pre-licensing requirements. LPA will submit notification to CAB (Centralized Application Bureau) in Sacramento for final review prior to license being issued. Applicant was informed today that the final approval will be processed by CAB in Sacramento.

Exit interview was conducted and a copy of this report was left with the applicant.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024
LIC809 (FAS) - (06/04)
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