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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701008
Report Date: 02/10/2022
Date Signed: 02/28/2022 02:15:39 PM


Document Has Been Signed on 02/28/2022 02:15 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:PLACE CALLED HOMEFACILITY NUMBER:
392701008
ADMINISTRATOR:VARGAS, BRANDIFACILITY TYPE:
740
ADDRESS:25820 MAGNOLIA AVETELEPHONE:
(714) 948-0381
CITY:ESCALONSTATE: CAZIP CODE:
95320
CAPACITY:11CENSUS: 10DATE:
02/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Nataley Martinez and Brandi VargasTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPA's) Michael Bilger and Maja Jensen arrived at this facility unannounced on 02/10/22 at 9:55 AM to conduct an annual inspection visit. Upon arrival, Licensee Nataley Martinez confirmed that the facility has no positive COVID-19 cases within the last 10 days.

LPAs met with licensee, Nataley Martinez and Administrator Brandi Vargas, and explained the purpose of the visit. LPAs toured the facility with Administrator, Brandi Vargas, at 10:30 AM. Administrator Brandi Vargas holds current certification #6055510740 good through 9/1/22.

LPA sinspected facility including common areas, resident units including bathrooms, kitchen, food storage areas, medication storage, garage, laundry room, front and backyard to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA's observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. LPA's measured hot water temperatures in the bathroom. Hot water measured within the required range of 105-120 degrees. LPA observed there to be a sufficient amount of perishable and non-perishable food supply on hand. Medications, toxins, and knives were inaccessible to residents. Smoke detectors are present throughout the facility. Facility also has carbon monoxide detectors. Fire extinguisher was purchased on 2/17/21 and will need servicing in the near future. First aid kit was observed up to date. LPAs also conducted the infection control domain tool.

Per California Code of Regulations, Title 22, no deficiencies were observed during the course of this visit. An exit interview was conducted with Brandi Vargas and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2022
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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