<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006020
Report Date: 08/06/2024
Date Signed: 08/06/2024 11:42:52 AM

Document Has Been Signed on 08/06/2024 11:42 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:KAROL'S KORNERFACILITY NUMBER:
306006020
ADMINISTRATOR/
DIRECTOR:		ROCHE, LISAFACILITY TYPE:
740
ADDRESS:305 N DIANA PLACETELEPHONE:
(714) 553-8292
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 6CENSUS: 4DATE:
08/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Lisa RocheTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit on this day for the purpose of conducting a Required - 1 Year inspection. LPA met with Caregivers Mary Grace Dominguez and Jhonny Ang. Administrator Lisa Roche arrived shortly after. Facility is a one story house with 6 private bedrooms, 3 bathrooms, an attached garage, a living room, a dining room, and kitchen. Facility is using existing garage storage room as a staff bedroom. There is a large back yard with 1 exit way on each side of the house, plus a gate that opens into the back street and a community park. There is a covered patio with seating for the residents and visitors. LPA observed and spoke to 4 of 4 residents. No resident is receiving Hospice care. LPA observed the facility to be clean and in good repair. LPA observed hallways and walkways are free of obstruction. The home is maintained at a comfortable temperature. Lighting is sufficient for safety and comfort. Bedrooms were observed to be spacious and easily accommodate furnishings such as lamps, chair, dresser and a bed. Bathroom were observed to be clean, have a supply of soap and paper towels. Hot water temperature was within regulatory requirements. Linen and hygiene supplies were stocked. Emergency Phone Numbers and Exit Plan were reviewed. Food prep area is clean and organized. Food supply meets the requirement of one (1) week supply of non-perishable and two (2) day supply of perishables. Smoke detectors and carbon monoxide detectors were found to be operational. Fire Extinguishers were charged and mounted. Stove burners, dishwasher, microwave, washer, and dryer are operational. Chemicals and sharps are made inaccessible to the residents. Laundry is done in the garage. Medications are centrally stored in a locked kitchen cabinet. Medications reviewed appear to have been dispensed accurately. LPA Martinez interviewed 2 of 2 staff and reviewed resident and staff files. LPA observed the following but not limited to: admission agreements, physician reports, consent forms and personal rights. LPA review staff files and observed the following but not limited to: criminal record clearance, criminal record statement, First Aid, and TB test. LPA noted Administrator's certificate expired on 7/15/2024 and is awaiting current one from Sacramento. Based on the observations made during today’s visit, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator and a copy of this report was provided at the end of the visit via email.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/06/2024 11:42 AM - It Cannot Be Edited


Created By: Lydia Martinez On 08/06/2024 at 10:39 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: KAROL'S KORNER
FACILITY NUMBER: 306006020

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87305(b)
Alterations to Existing Building or New Facilities (b) The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists. This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above, in that storage room in the garage was converted into staff bedroom prior to being cleared by the local fire authority which poses an immediatel Health, Safety, or Personal Rights risk to persons in care.
POC Due Date: 08/07/2024
Plan of Correction
1
2
3
4
Licensee agrees to cease using the garage as a converted living area immediately. Licensee to submit an LIC200, updated facility sketch, a letter requesting a fire clearance along with $25 check payable to DSS mailed to the Department by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2