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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006321
Report Date: 03/05/2025
Date Signed: 03/05/2025 11:42:33 AM

Document Has Been Signed on 03/05/2025 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:BELFORD LIVINGFACILITY NUMBER:
306006321
ADMINISTRATOR/
DIRECTOR:		JABONERO, MACRINAFACILITY TYPE:
740
ADDRESS:2255 BELFORD AVETELEPHONE:
(714) 504-5371
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 6DATE:
03/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Edna TamondongTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On March 5th, 2025 Licensing Program Analyst (LPA) William Vanegas conducted an unannounced inspection for the purposes of an annual inspection. Upon arrival LPA Vanegas was greeted and granted entry to the facility, and advised the purpose of the inspection. LPA Vanegas set up equipment and began a tour of the facility and observed the following.

This is a one storied home with four bedrooms, three bathrooms one of which is a private bathroom and two that are shared bathrooms. There is an attached two car garage as well. LPA Vanegas observed kitchen area to be clean and free of any mildew, debris, or insects. LPA Vanegas observed a stove, dishwasher, microwave, washer, dryer, and a refrigerator that all appeared to be in good repair, and tested operational. LPA Vanegas observed a two day supply of perishable food and a seven day supply of non-perishable food as well as a sufficient amount of emergency water.

LPA Vanegas observed resident bathrooms to be clean and free of debris and mildew. Water faucets and toilets tested to be operational, and bathrooms consisted of all the required furnishings such as grab bars, slip resistant floor matts, and a shower chair. Water tested between 106.5 and 109.2 Degrees.

LPA Vanegas observed residents bedrooms to be clean and in good repair. LPA Vanegas observed rooms to have all required furnishings such as a chair, reading lamp, chest drawers, enough storage space for personal belongings, a bed, and clean linens in good repair, meaning no strains or tears.

LPA Vanegas observed all required postings to be posted on entry way of the facility. LPA Vanegas observed fire extinguishers to be up to date, and fully charged. LPA Vanegas observed all smoke and carbon monoxide detectors to be in good repair and operational.
CONTINUED ON LIC809C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BELFORD LIVING
FACILITY NUMBER: 306006321
VISIT DATE: 03/05/2025
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LPA Vanegas observed all toxins, sharps, and medications to be locked away and inaccessible to residents in care. LPA Vanegas reviewed medications with Administrator (AD) Edna Tamondong. Per LPA Vanegas review all medications are being documented correctly, and being administered per physicians orders.

LPA Vanegas reviewed four employee files and six resident files. All files (Resident and Staff) have all required documents and annual staff training is up to date. LPA Vanegas observed a first aid kit to have all required equipment such as adhesive tape, bandages, scissors, tweezers, and a thermometer.

LPA Vanegas observed outside of the facility to be clean and free of any debris or obstructions along the exit routes. All side doors are self latching and unlocked. There is an outdoor shaded sitting area, and the back yard is large enough to accommodate any outdoor activities upon the request of residents in care.

Based on observations made today, no deficiencies will be cited per title 22 chapter 8 division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC809 (FAS) - (06/04)
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