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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300613256
Report Date: 04/26/2023
Date Signed: 04/26/2023 10:05:28 AM

Document Has Been Signed on 04/26/2023 10:05 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:LITTLE HARBOR BOARD & CAREFACILITY NUMBER:
300613256
ADMINISTRATOR:PARKER, STACEY SHAWNFACILITY TYPE:
735
ADDRESS:551 S. HARBOR BLVD.TELEPHONE:
(714) 999-9990
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 4CENSUS: 1DATE:
04/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Stacey ParkerTIME COMPLETED:
10:20 AM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with Administrator (AD) Stacey Parker and discussed the purpose of the inspection.LPA reviewed Infection Control requirements. At about 8:15AM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure. This is a one-story home. Facility is a 3-bedroom, 2-bathroom, one-story house with a detached garage that is being used for storage. There is a back yard with a patio cover for the clients. LPA observed AD and 1 client present at the facility. Client Bedrooms. The 2 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Lamps, chairs, linens, and storage for each client bedroom inspected. Staff Bedrooms. The 1 staff bedroom is spacious and will easily accommodate the staff’s furnishings. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 113.7 and 114 F degrees. LPA inspected all rooms in the facility. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen drawer. Toxins: observed locked under the kitchen sink. Medication cabinet is locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are fully paid. At about 9:00AM, LPA reviewed 1 client file and 1 staff file, interviewed 1 client and 1 staff, inspected medications for 1 client, and inspected client money and ledger for 1 client. During the inspection, LPA and AD observed the following: administrator did not complete HIV/TB training within the last 2 years.
Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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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Document Has Been Signed on 04/26/2023 10:05 AM - It Cannot Be Edited


Created By: Sean Haddad On 04/26/2023 at 09:55 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LITTLE HARBOR BOARD & CARE
FACILITY NUMBER: 300613256

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and documents, administrator did not complete HIV/TB training within the last 2 years.
POC Due Date: 05/10/2023
Plan of Correction
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Licensee stated they will sign up for the training immediately and send proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023


LIC809 (FAS) - (06/04)
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