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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006178
Report Date: 04/24/2024
Date Signed: 04/24/2024 10:07:53 AM

Document Has Been Signed on 04/24/2024 10:07 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:POLLY'S PLACEFACILITY NUMBER:
306006178
ADMINISTRATOR/
DIRECTOR:		VALENCIA, POLLYFACILITY TYPE:
740
ADDRESS:2143 W. FIR AVE.TELEPHONE:
(949) 412-2579
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 6DATE:
04/24/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:41 AM
MET WITH:Polly ValenciaTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre conducted an unannounced case management visit in conjunction with complaint visit 22-AS-20240416125427. LPA met with Administrator Polly Valencia. LPA explained the reason for the visit. During the visit LPA observed the following. The smoke detectors in the kitchen and TV room next to the kitchen that both smoke detectors have been removed. LPA observed that the base plates are attached with the wires to connect the smoke detectors hanging freely from the ceiling/wall. LPA toured the facility. LPA observed the bathroom next to the living room does not have a screen in the window.

Deficiencies are being cited per Title 22, Division 6 of the California Code of regulations. An exit interview was conducted and a copy of the report along with the LIC 809D, LIC 421IM and appeal rights was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2024
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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Document Has Been Signed on 04/24/2024 10:07 AM - It Cannot Be Edited


Created By: Joseph Alejandre On 04/24/2024 at 08:53 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: POLLY'S PLACE
FACILITY NUMBER: 306006178

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/25/2024
Section Cited
CCR
87203

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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 is not being met as evidenced by:
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Licensee agrees to install smoke detectors in the kitchen and TV room next to the kitchen and to forward proof to LPA by POC due date.
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LPA observed the smoke detectors in the kitchen and TV room have been removed. This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED.
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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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024


LIC809 (FAS) - (06/04)
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