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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701008
Report Date: 03/01/2022
Date Signed: 03/01/2022 01:53:25 PM


Document Has Been Signed on 03/01/2022 01:53 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
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: 8DATE:
03/01/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Jose GonzalezTIME COMPLETED:
01:51 PM
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On 3-1-22, at 12:40pm Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a plan of correction (POC) visit for a deficiency issued on 2-25-22 from complaint #27-AS-20220202144224. LPA met with Jose Gonzalez and explained the purpose of the visit. Administrator Brandi Vargas was notified by phone of LPA's visit and gave permission for Jose Gonzalez to accommodate LPA and sign in her absence. LPA verified a refund cashier's check was issued to Resident1 (R1) responsible person on 2-26-22 and was deposited accordingly. During this POC visit, LPA toured facility and conducted a health and safety check. Facility temperature is at 75*F. Food supply is adequate to meet resident needs. According to Jose there are currently 8 residents residing at facility with a capacity of 11. LPA counted 8 residents in care during today's visit. Administrator stated a resident moved out voluntarily with two more planning to move out today voluntarily. Facility has six bedrooms. Five bedrooms are shared.

Facility is clean and sanitary throughout with no foul odors noted. No obstructions to fire exits noted. All sharp objects, toxins, and other dangerous items are inaccessible to residents in care. LPA also requested the following documents from licensee: Copy of lease agreement, copy of 60-day notice, and copy of facility's liability insurance. The documents requested were not produced by licensee and were not observed by LPA during visit.

Plan of correction has been cleared during this visit. No deficiencies are cited during today's visit. An exit interview was conducted with Jose Gonzalez and a copy of this report was left with Jose.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022
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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