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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006495
Report Date: 08/19/2024
Date Signed: 08/19/2024 12:00:59 PM

Document Has Been Signed on 08/19/2024 12:00 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:HILLS OF SANTA TERESA, THEFACILITY NUMBER:
306006495
ADMINISTRATOR/
DIRECTOR:		NEPOMUCENO, MARICELFACILITY TYPE:
740
ADDRESS:17698 SANTA TERESA CIRCLETELEPHONE:
(714) 430-7672
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 5DATE:
08/19/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Licensee Maricel Neponuceno TIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Jenifer Tirre visited this facility for the purpose of conducting a Change of Ownership Pre-Licensing evaluation. During visit LPA observed five residents in care. Facility is a single story residential home. LPA along with Licensee Maricel Neponuceno, Administrators Diane Mahinay and Jeff Bencito toured facility at 10:05AM and observed the following:

Fire clearance approval was received on 06/24/24. Structure: Facility is a one story, 4 bedroom (two private bedrooms and two shared bedrooms) and four bathrooms house with attached garage and a beige exterior. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: All Residents bedrooms meet Licensing requirements. Bathrooms: resident bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars and non-skid surface mats in the shower. Linens & Hygiene Supplies: Facility has adequate supply of linens, blankets and towels. Facility has hygiene products for each resident. Emergency Phone Numbers and Exit Plan: Facility has Emergency Plan posted on wall. Food Service: Facility has adequate supply of 2 day perishables as well as 7 day non-perishables in the pantry/ refrigerator, as well as ample emergency food and water supply. Smoke Detectors: Smoke detectors/ carbon monoxide detector are centrally wired and were tested operational. Facility has one fire extinguisher. Fire extinguisher is mounted and fully charged. Facility has audible alarms on all sliding/exit doors. Appliances: Facility has operating gas stove, refrigerator, microwave,washer and dryer. Toxins: LPA observed toxins secured in laundry storage area and Sharps secured in locked drawer. Water Temperature: Tested and recorded between 114.6 to 116.4 degrees F. in facility bathrooms. Reading Material Games, and Equipment:
facility does exercises, music therapy, puzzles, games, books and coloring books. Medications, First-Aid Kit & Book: Facility has first aid kit present at the facility with proper components. Facility has a secured location for medications and facility files. Backyard: LPA observed the facility perimeter is secured by wall with a self latching gate on both sides of facility as required. LPA observed shaded outdoor seating.

CONTINUED ON 809C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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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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: HILLS OF SANTA TERESA, THE
FACILITY NUMBER: 306006495
VISIT DATE: 08/19/2024
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Administrator's Certificate observed on wall expiring May, 15, 2026.

Component III Orientation was waived during this pre licensing visit due to Licensee presently operating several facilities throughout Orange county.

No deficiencies noted during todays visit. The pre-licensing visit has been completed. This location is ready for licensure.


An exit interview was conducted with Licensee and Administrators and a copy of report was left at facility.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC809 (FAS) - (06/04)
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