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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006534
Report Date: 10/14/2024
Date Signed: 10/14/2024 03:53:32 PM

Document Has Been Signed on 10/14/2024 03:53 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:FELBERT HOMESFACILITY NUMBER:
306006534
ADMINISTRATOR/
DIRECTOR:		JABONERO, JEREMIASFACILITY TYPE:
735
ADDRESS:10269 CLAUDIA AVETELEPHONE:
(714) 679-5347
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 4CENSUS: 0DATE:
10/14/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Lito Rodriguez, Maria Gingras, Jeremias JaboneroTIME VISIT/
INSPECTION COMPLETED:
04:10 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 Lito Rodriguez, Maria Gingras and Administrator Jeremias Jabonero.

Initial application: To operate an Adult Residential Care Facility, with a total capacity of 4, of which 3 will be ambulatory clients, and 1 bedridden client was submitted to the department for licensure.



Fire clearance: Orange County Fire Authority granted the Fire Clearance May 28, 2024

Structure: The facility is a single level structure, with an attached garage. There’s a total of 5 bedrooms, 4 of which will be used for clients and 1 room will be used as a staff office space. There’s one living room space, one dining room, and two bathrooms for clients. Bedrooms (Clients): All bedrooms have the required furnishings: bed, lamp, chair, and storage space. An additional supply of linens for each client is stored in the bedroom. 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 111.9 degrees Fahrenheit and 111.5 degrees Fahrenheit. Kitchen: The gas stove was operational, and all burners were in good working order. Client medications will be stored in cabinets above the counter tops near the refrigerator. Next to the locked medication cabinets, there’s additional locked cabinets with a lock box for refrigerated medications, and two first aid kits with all the required elements. Food Service: A sample menu was observed on the refrigerator and posted on the facility postings board at the entrance of the facility. The applicant is familiar with the perishable and nonperishable food supply requirements.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
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: FELBERT HOMES
FACILITY NUMBER: 306006534
VISIT DATE: 10/14/2024
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 Office Area: One of bedrooms has been converted into an office space. Staff and client files will be stored in the office in locked filing cabinets. Client P&I funds and additional supplies like linens and hygiene items will be stored in the locked office area as well. Garage/Laundry: The garage is used to store miscellaneous facility items. An additional refrigerator that will be used to store an additional food supply was observed. An emergency supply of food items and an emergency supply of water was observed. There's a washer and dryer in the locked garage.

Client & Staff Files: Client and staff files are stored in the office area and kept in locked filing cabinets. Medications/First-Aid Kit: Medications will be locked in the kitchen cabinets above the counter top. Linens & Hygiene Supplies: Additional linens are stored in the clients bedrooms, and will be stored in the clients bathrooms, and the office area when storage space is needed. Toxins/Sharps: All toxic chemicals and cleaning solutions are inaccessible to clients and locked under the sink in the kitchen. Knives and sharp objects are locked in a cabinet near the stove below the counter top.

Backyard/Exterior: The backyard was clean and organized. Walkways were free of obstruction. There’s a shaded patio area with a table and chairs. Side exit gates are self-closing and self-latching. Bodies of Water: No bodies of water were observed.

Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational. Fire Extinguisher: Observed full charged mounted on the wall above the screening station near the entrance.

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, and sample menu on the facility postings board near the entrance.

Component III: Was presented at the end of the visit.

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 Lito Rodriguez, Maria Gingras, and Administrator Jeremias Jabonero.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
LIC809 (FAS) - (06/04)
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