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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006266
Report Date: 03/22/2023
Date Signed: 03/22/2023 03:04:53 PM

Document Has Been Signed on 03/22/2023 03:04 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:DEVOTED FAMILY CARE HOMEFACILITY NUMBER:
306006266
ADMINISTRATOR:MARICA, ABELFACILITY TYPE:
740
ADDRESS:12902 WHEELER PLACETELEPHONE:
(949) 232-9619
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 0DATE:
03/22/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Abel Marica
Claudia Olteanu		TIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility and met with designated Administrator (AD) Abel Marica and Facility Manager, Claudia Olteanu. An application to operate an Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (0) non-ambulatory, and (6) bedridden residents was received by CCL on 11/15/2022.

Structure:
The facility is a single-story home with six resident bedrooms, four bathrooms, living room, kitchen, three staff bedrooms, one staff office, one storage room, and an attached two car garage with a separate staff dwelling, that includes two bedrooms and one bathroom. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the living room area. There is a back yard with no exit gates on either side of the house. There is a shaded seating area in the backyard. LPA did not observe any obstacles or hazards in the backyard.

Client Bedrooms
All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened.

Signal system
There is no signal system.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
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: DEVOTED FAMILY CARE HOME
FACILITY NUMBER: 306006266
VISIT DATE: 03/22/2023
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Medications, First-Aid Kit & Book:
Medication will be stored in a locked closet. First aid kit is stored with the medication. The first aid kit has all the required elements.

Resident & Staff Files:
Records will be kept locked in storage cabinet located in the staff office.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
All fire extinguishers are fully charged.

Reading Material, Games, Equipment & Materials:
The facility has board and card games, as well as sensory toys that will be kept for resident use.

Fire clearance:
Was approved by a fire inspector of Orange County Fire Authority on 01/30/2023. No special conditions noted.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Bedrooms Staff:


Three bedrooms will be occupied by staff.

Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 111.7 degrees Fahrenheit.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
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: DEVOTED FAMILY CARE HOME
FACILITY NUMBER: 306006266
VISIT DATE: 03/22/2023
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Linens & Hygiene Supplies:
Supply of extra linen was stored in the storage room.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was posted and visible.

Food Service:
There is a supply of 2-day perishable and 7-day of non-perishable food on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas five burner stove with 1 oven, 1 refrigerator, dish washer, microwave, washer, and dryer are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC809 (FAS) - (06/04)
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