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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006539
Report Date: 08/19/2024
Date Signed: 08/20/2024 06:58:32 AM

Document Has Been Signed on 08/20/2024 06:58 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CONNECTIONS MENTAL HEALTHFACILITY NUMBER:
306006539
ADMINISTRATOR/
DIRECTOR:		ALCALA, PABLOFACILITY TYPE:
772
ADDRESS:17841 LINCOLN STREETTELEPHONE:
(949) 742-0172
CITY:VILLA PARKSTATE: CAZIP CODE:
92861
CAPACITY: 6CENSUS: DATE:
08/19/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:30 AM
MET WITH:Pablo Alcala, Jaime Courtney and Caitlin GarciaTIME VISIT/
INSPECTION COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit. An initial application to operate a Social Rehabilitation Facility was submitted to CCL on 03/22/2024 for a capacity of six ambulatory clients. Upon entry, facility appears clean, safe and sanitary.

LPA along with Management Team toured the facility at 7:42 AM and observed the following:
Structure: Facility is a two story, 5 bedroom, 3 bathroom house with an attached garage and a beige exterior. First floor has 1 bedroom used as a therapy room and one restroom. Second story houses 4 bedrooms and 2 restrooms. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Clients: Rooms will be single and double occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: All client bathrooms have a working toilet/ wash basin. Facility has sanitizer/ soap and paper towels in the restrooms. Linens & Hygiene Supplies: Facility has bedding, towels and hygiene supplies for clients in care. Emergency Phone Numbers and Exit Plan: Emergency plan/ phone numbers located in facility entrance. Food Service: Facility does not have 2 day perishables but has 7 day non-perishables. There are no clients present. LPA observed ample emergency food and water as well as a facility menu. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are hard wired and were tested operational. Fire extinguishers are mounted and charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: Facility has secured area for toxins/ sharps in secured closet. Water Temperature: Tested and recorded between 110.1 and 111.2 degrees F in all restrooms. Medications, First-Aid Kit & Book: First aid kit observed contained all required items. Kit contained a first aid manual. Facility to use an electronic medication administration record. Client & Staff File: Records are electronically stored. Reading Material, Games, and Equipment: Facility has an activity schedule including exercise, arts and crafts and outings in the community. CONTINUED ON LIC 809C DATED 08/19/2024.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CONNECTIONS MENTAL HEALTH
FACILITY NUMBER: 306006539
VISIT DATE: 08/19/2024
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Backyard: LPA observed a clean backyard with ample shaded seating for clients. Exit gates are self latching and unlocked. Fire Clearance: Approved for six ambulatory clients on 06/04/2024

During the visit, LPA observed the following items to be addressed:
  • Facility to obtain an emergency evacuation chair for the second floor of facility.
  • Facility to clean outdoor table and chairs
  • Facility to remove tiles and debris on side of the house.



Component III conducted during the visit.




Exit interview conducted and a copy of this report will be left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC809 (FAS) - (06/04)
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