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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004547
Report Date: 07/10/2024
Date Signed: 07/10/2024 12:20:35 PM

Document Has Been Signed on 07/10/2024 12:20 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PACIFIC SHORES OF LAKE FORESTFACILITY NUMBER:
306004547
ADMINISTRATOR/
DIRECTOR:
BENIGNO BULANADIFACILITY TYPE:
740
ADDRESS:21521 MORESBY WAYTELEPHONE:
(949) 716-8903
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 6DATE:
07/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Benigno BulanadiTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator Benigno Bulanadi and explained the reason for the visit. Benigno Bulanadi's Administrator's certificate expires on July 17, 2025. The facility is a one story home with 5 bedrooms, staff room, 4 bathrooms, kitchen, laundry room, dining room, living room with a fireplace, family room, caregiver room and a 2 car garage. LPA observed the See Something, Say Something poster (PUB 475) posted in the entry way of the facility. LPA observed the fireplace in the living room is not screened. The Administrator reported that fireplace is never used. LPA and the Administrator toured the facility. LPA observed all 5 resident rooms had the required furnishings and bed linens. Smoke detectors/carbon monoxide detectors tested operational. All 4 bathrooms are clean and operational. Hot water measured 108.5 to 109.2 degrees Fahrenheit in all bathrooms. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. Knives are kept locked in a kitchen drawer. The garage is kept locked and used for storage. No obstacles or hazards observed inside of the facility. LPA and the Administrator toured the backyard. LPA observed old bed rails and tiles stored on the North side of the house that does not have the exit gate. LPA observed there are two shaded seating areas in the backyard. No bodies of water observed. LPA observed the outside fireplace is not screened. The side of the house with the exit gate (South side) is free of obstacles and hazards. The exit gate is operational and self closing. LPA reviewed 6 residents records and medications, no discrepancies observed. LPA reviewed 2 staff files, no discrepancies observed, both staff members had the required training including first/CPR training. LPA inspected the first aid kit. The first aid kit has all the required elements. The last facility emergency drill was conducted on May 31, 2024. LPA observed the facility has internet service (WiFi) but does not have a dedicated internet device for residents. No deficiencies are being cited as a result of this visit. Three (3) technical violations issued (LIC 9102). An exit interview was conducted and a copy of the report provided along with the technical violations.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2024
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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