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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090001
Report Date: 07/20/2023
Date Signed: 07/20/2023 11:04:51 AM

Document Has Been Signed on 07/20/2023 11:04 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:SNCH-ELM HOMEFACILITY NUMBER:
306090001
ADMINISTRATOR:LAURA R. RUBIOFACILITY TYPE:
735
ADDRESS:1728 E. ELM ST.TELEPHONE:
(714) 772-7298
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 6CENSUS: 2DATE:
07/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Alma PayumoTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Staff Wendell Payumo. LPA met with House Manger (HM) Alma Payumo and discussed the purpose of the inspection.

During the inspection LPA and HM conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a one-story house with three client bedrooms and two bathrooms. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. There is a shaded sitting area in the front yard. LPA observed two staff and two clients present. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 108.3 F degrees.

LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted in the dining room area of the facility. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Sharps were observed locked underneath the kitchen sink. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication cabinet was observed to be locked and lock is operational. LPA reviewed two out of two client files and two staff files. LPA interviewed two out of two clients and the two staff present.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
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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