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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006353
Report Date: 12/20/2024
Date Signed: 12/20/2024 02:53:14 PM

Document Has Been Signed on 12/20/2024 02:53 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:COLUMNS CARE HOMEFACILITY NUMBER:
306006353
ADMINISTRATOR/
DIRECTOR:
HSI, CATHERINEFACILITY TYPE:
740
ADDRESS:17332 LAURIE LNTELEPHONE:
(732) 589-4692
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 6CENSUS: 5DATE:
12/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:58 PM
MET WITH:JCathreine HSITIME VISIT/
INSPECTION COMPLETED:
04:26 PM
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Licensing Program Analysts (LPA) Samer Haddadin conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA met with Administrator (AD) Catherine HSI and explained the reason of the visit.

This facility is a one-story home with 4 residents’ bedrooms and two bathrooms and one staff room and one staff restroom. LPA toured the inside and outside of the facility and noted the following:

Facility appeared clean, safe, and sanitary. All residents’ rooms had required elements, including bed, chair, closet space, and ample lighting. Facility had extra linens and hygiene supplies for all residents. Restrooms were stocked with soap and paper towels. Hot water measured at 106.1 degrees Fahrenheit in both bathrooms. LPAs observed the facility had a two-day supply of perishables and a seven-day supply of non-perishable. LPA observed hallways and walkways were free of obstruction.

LPA observed the fire extinguisher was charged based on the arrow pointing into the green zone. The service tag indicated the extinguisher was last serviced on October 9th, 2024. Facility staff tested smoke and carbon monoxide detectors, and all were operational.

Chemicals and toxins are locked up in the garage and under the kitchen sink. LPA noted the facility's knives and sharps were secured and locked in a kitchen cabinet. Medication for each resident was kept locked and secured and inaccessible to resident in care.

LPA reviewed two residents’ files and medications, which no discrepancies were observed. LPA reviewed two staff files. All files of staff and residents contained all required documentation. Upon review of records, the facility is up to date with required quarterly fire drill, which was last conducted on November 6th, 2024. The administrator certificate expires on August 28, 2025.


No deficiencies were noted during today's inspection visit. An exit interview was conducted, and a copy of this report was provided to the facility AD.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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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