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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006162
Report Date: 08/14/2024
Date Signed: 08/14/2024 01:32:43 PM

Document Has Been Signed on 08/14/2024 01:32 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:COLORADO RESIDENTIAL CAREFACILITY NUMBER:
306006162
ADMINISTRATOR/
DIRECTOR:
FRANCISCO, ANALIEFACILITY TYPE:
740
ADDRESS:436 COLORADO STTELEPHONE:
(949) 290-3917
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 6DATE:
08/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:47 AM
MET WITH:Mareties Pontoy, Administrator and Theresa Bernabe, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:48 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by Dante Pontoy, Caregiver. Administrator Mareties Pontoy and Licensee Theresa Bernabe joined the inspection approximately 15 minutes after LPA's arrival.

The facility is a one-story home with four resident bedrooms, three resident bathrooms, kitchen/dining room, living room, backyard, laundry room, storage room and detached 2-car garage. All resident rooms had required elements, including bed, chair, closet space and ample lighting. Facility has extra linens and supplies for residents in the garage. Restrooms are stocked with soap and paper towels. LPA measured water in resident bathrooms to be between 105 and 120 degrees Fahrenheit. LPA noted Fire Extinguishers were last serviced on 02/20/2024 according to the service tag on them. LPA observed the smoke/carbon monoxide detectors to be operational. Facility keeps emergency water and emergency disaster supplies in the garage.



LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in cabinets. Knives are locked up separate from toxic chemicals. Medication for each resident is kept locked in a cabinet in the kitchen. The backyard has a shaded sitting/lounging area. Exit gate is unlocked. LPA observed exit gate to be unobstructed. LPA observed a sample menu and activity calendar in the facility. LPA reviewed three of the six resident files and three staff files. LPA also reviewed medication for three out of six residents. LPA interviewed two residents and one staff.

Based on today's inspection, no deficiencies are being issued. An exit interview was conducted and a copy of
this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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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