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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006182
Report Date: 09/20/2022
Date Signed: 09/20/2022 02:40:34 PM

Document Has Been Signed on 09/20/2022 02:40 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:LUCHEN SANTOS HOMES INC.FACILITY NUMBER:
306006182
ADMINISTRATOR:SANTOS, MARGIE ROSE AFACILITY TYPE:
740
ADDRESS:6075 BELLE AVENUETELEPHONE:
(714) 858-0046
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 4CENSUS: 0DATE:
09/20/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Margie SantosTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Jerome Haley made an announced visit for the purpose of a pre-licensing evaluation. LPA Haley was greeted and granted entry by applicant Margie Santos. Upon entry, LPA Haley was temperature screened and signed in at the entrance. LPA Haley observed a COVID screening station near the entrance of the facility equipped with a temperature thermometer, hand sanitizer, surgical mask, and sign in sheets.

An initial application to operate an Residential Care Facility for the Elderly, for a capacity of 4 non-ambulatory residents was submitted to CCL on 3/14/2022.



Structure:
The facility is a single level structure, with an attached garage. There are four resident bedrooms, one living room, and one dining room. Resident bedrooms are spacious and equipped with the required furnishings: bed, lamp, chair, and storage space.

Backyard/Exterior:
There is a large back yard with 2 exit ways on each side the house with shaded seating area for residents. There's a locked storage shed in the backyard used for storing miscellaneous items.

Air/Heating:
Central air/heating system installed with a central panel to control entire house.

Bedrooms Residents:
All bedrooms are for non-ambulatory residents and have sliding glass exit doors for 4 non-ambulatory residents. Bedrooms # 1 & 2 are connected and share an exit door.

CONTINUED on LIC809-C
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LUCHEN SANTOS HOMES INC.
FACILITY NUMBER: 306006182
VISIT DATE: 09/20/2022
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Bathrooms:
Bathroom one is equipped with a working toilet, wash basin, and walk in shower. Hot Water Temperature in Bathroom #1 was measured at 112.8 degrees Fahrenheit and 109.2 degrees Fahrenheit in bathroom #2.

Linens & Hygiene Supplies:
Adequate supply of linen was stored in a cabinet in the kitchen/dining room. Hygiene supplies are stored in a cabinet above the washer and dryer

Emergency Phone Numbers, House Rules, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed, House Rules and a Menu posted near the refrigerator in the kitchen.

Food Service:
An adequate supply of 7-day non-perishable and 2-day supply of perishable items were observed in the kitchen. There was an extra supply of perishable food items stored in the garage.

Smoke Detectors:
Smoke detectors are hardwired and tested operational.

Appliances:
Gas 5 burner stove, single oven, 2 refrigerators (kitchen and garage), dish washer, microwave, washer, and dryer are clean and noted to be operational.

Toxins:
All toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents are stored in a locked cabinet above the washer and dryer.

CONTINUED on LIC809-C
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LUCHEN SANTOS HOMES INC.
FACILITY NUMBER: 306006182
VISIT DATE: 09/20/2022
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Medications, First-Aid Kit & Book:
Medication and first aid kit are stored in a locked cabinet near the facility entrance and inaccessible to residents.

Resident & Staff Files:
Resident files and staff files are kept in a locked closet near the entrance of the facility and inaccessible to residents.

Bodies of water:
No bodies of water were observed.

Fire Extinguisher:
Observed full charged and mounted in the kitchen. There is an additional fire extinguisher located in the garage.

Fire clearance:
Orange County Fire Authority granted the Fire Clearance July 22, 2022

Component III:
Was presented to applicant Margie Santos during the visit.

No corrections need to made at this time. The facility will be recommended for licensure.

An exit interview was conducted and a copy of this report was provided to applicant Margie Santos.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
LIC809 (FAS) - (06/04)
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