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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006569
Report Date: 10/17/2024
Date Signed: 10/17/2024 11:06:57 AM

Document Has Been Signed on 10/17/2024 11:06 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:NICO BRIGHT HORIZONS CARE HOME - DONNA LANEFACILITY NUMBER:
306006569
ADMINISTRATOR/
DIRECTOR:		MENDOZA, CATHERINEFACILITY TYPE:
735
ADDRESS:11771 DONNA LANETELEPHONE:
(213) 400-3389
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 6CENSUS: 0DATE:
10/17/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Catherine MendozaTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Lydia Martinez made an announced visit to conduct a Pre-Licensing inspection. LPA identified herself and was granted entry into the home. An initial application to operate an Adult Residential Facility was submitted to Community Care Licensing on 04/25/2024 for a capacity of six (6) Ambulatory clients. Administrator Catherine Mendoza has an Administrator certificate valid until 01/31/2025. Upon entry, facility appears clean, safe and sanitary.

LPA along with Applicant toured the facility and observed the following:
Structure: Facility is a one story, 5 bedroom, 2 bathroom house with an attached garage and a gray exterior. Facility has an office for Administrative work. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Clients: Two rooms will be single occupancy and other two will be double occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: Client bathrooms have a working toilet/wash basin. Facility has sanitizer/soap in the bathrooms. Linens & Hygiene Supplies: Facility has adequate 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: Applicant has some food but understands to have a 2 day supply of perishables and a 7 day of non-perishables at all times when clients are present. There are no clients present during this inspection. 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 under kitchen sink. Water Temperature: Tested and hot water temperature was within regulatory requirements.

(see LIC809C)
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: NICO BRIGHT HORIZONS CARE HOME - DONNA LANE
FACILITY NUMBER: 306006569
VISIT DATE: 10/17/2024
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Medications, First-Aid Kit & Book: First aid kit observed contained all required items, including First Aid Manual. Facility to be stored in Medication cart and will use a Medication Administration record.

Client & Staff File: Records to be stored in a locked cabinet in the office or locked cabinet in garage. Reading Material, Games, and Equipment: Facility has a variety of board games, an exercise machine, music, books, magazines and will plan outings in the community.

Backyard: LPA observed a clean backyard with an enclosed covered patio with seating for clients and visitors. Exit gate needs self latching mechanism that Applicant will install. Applicant understands not to put locks on gate.

Fire Clearance: Approved on 06/17/2024. Rooms 1, 2, 3, 4 are approved for Ambulatory Clients only. Staff room is approved located next to bathrooms.

Component III conducted during the visit.

During today's visit, LPA noted a door connecting the garage with enclosed patio and a large barn door type door in enclosed patio that are not noted on approved STD 850.

LPA explained that clarification is needed before facility is ready for licensure based on inspection. LPA spoke to Fire Inspector during today's visit. Applicant to submit updated Floor plan to Fire Inspector as agreed. Applicant also to install self latching mechanism on outside gate.

LPA to return when above has been completed.

Exit interview was conducted and a copy of this report was sent to email on file
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
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