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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002100
Report Date: 12/28/2023
Date Signed: 12/28/2023 04:15:45 PM

Document Has Been Signed on 12/28/2023 04:15 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SOMERSET HOMEFACILITY NUMBER:
306002100
ADMINISTRATOR:LENETTE L. BELENFACILITY TYPE:
735
ADDRESS:4950 SOMERSET ST.TELEPHONE:
(714) 739-2273
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 6CENSUS: 5DATE:
12/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Loraine Monzon, Lenette L. BelenTIME COMPLETED:
04:30 PM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Staff #1 (S1) Loraine Monzon and discussed the purpose of the inspection. Administrator (AD) Lenette L. Belen arrived during the inspection.
LPA reviewed Infection Control requirements. At about 2:00PM, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure: facility is a 6-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 3 staff and 4 clients present at the facility. Client Bedrooms: the 4 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms: LPA inspected the 2 staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at between 107 and 109 degrees F in the common client bathrooms. 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: observed. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the laundry room. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 2:45PM, LPA reviewed 5 client files and 4 staff files, interviewed 4 clients and 3 staff, inspected medications for 5 clients, and inspected client money and ledgers for 5 clients. During the inspection, LPA and AD observed the following: based on documents, the licensee did not ensure 3 out of 4 staff had completed health screenings.
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: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023
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 12/28/2023 04:15 PM - It Cannot Be Edited


Created By: Sean Haddad On 12/28/2023 at 03:51 PM
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: SOMERSET HOME
FACILITY NUMBER: 306002100

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documents, the licensee did not ensure 3 out of 4 staff had completed health screenings, which poses a potential safety risk to persons in care.
POC Due Date: 01/25/2024
Plan of Correction
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The licensee stated they will obtain health screenings for these staff and will submit 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: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023


LIC809 (FAS) - (06/04)
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