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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005932
Report Date: 04/28/2022
Date Signed: 04/28/2022 08:53:06 PM

Document Has Been Signed on 04/28/2022 08:53 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:A MOTHER THERESA CAREFACILITY NUMBER:
306005932
ADMINISTRATOR:PAO, WESLEYFACILITY TYPE:
740
ADDRESS:16192 CAIRO CIRCLETELEPHONE:
(714) 792-0967
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 6DATE:
04/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Wesley PaoTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced Case Management evaluation in conjunction with a 10-day complaint visit. LPA Martinez was greeted and granted entry into the facility by Staff Marujan Camilon, Heide Camilon, and Jonathan Marcelo. Administrator Wesley Pao arrived shortly after and explained the reason for the visit.

During the 10-day complaint initiation inspection, LPA interviewed 4 of 6 residents, and reviewed 6 resident files and staff files. LPA along with staff Camilon toured facility and observed the following:
  • Shed in backyard converted into staff living quarters.

During today's visit, the following deficiency was observed and is being cited per Title 22, Division 6, of the California Code of Regulations.

This report, along with LIC809D, LIC811 and Appeals Rights was reviewed with Administrator Pao and copies will be emailed.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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Document Has Been Signed on 04/28/2022 08:53 PM - It Cannot Be Edited


Created By: Lydia Martinez On 04/28/2022 at 04:09 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: A MOTHER THERESA CARE
FACILITY NUMBER: 306005932

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2022
Section Cited
CCR
87203

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Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by:
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Administrator agrees to remove furniture including staff's personal belongings from the shed and designate an area within the living area for staff's use and provide adequate living quarters within the facility in conformity to regulatios adopted by the State Fire Marshall. Shed shall only be used for storage,
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LPA observed a storage shed in the back yard to have been converted into a live-in staff room. This was acknowledged by AD and staff. This poses an immediate threat to the health and safety of the residents in care.
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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:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022


LIC809 (FAS) - (06/04)
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