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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606024
Report Date: 09/21/2021
Date Signed: 09/21/2021 04:47:53 PM

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:MAUREEN GUEST HOMEFACILITY NUMBER:
300606024
ADMINISTRATOR:MCKENZIE, VICTORFACILITY TYPE:
740
ADDRESS:9362 MAUREENTELEPHONE:
(714) 539-0391
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:6CENSUS: 6DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:57 PM
MET WITH:Administrator, Victor MckenzieTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted, granted entry into the facility by Staff and explained the reason for the visit.

During the visit LPA toured the facility with Administrator Victor Mckenzie. Facility is a 4 bedroom,( 3 resident bedrooms 1 staff bedroom) and 2 bathrooms single story home. There are 6 Residents in care. LPA observed proper covid signage at front entrance of facility as well as sign in station. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring June 5, 2023. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper and paper towels. Restrooms had proper hand washing signs posted. Residents were observed relaxing in the Living room watching TV. Facility has 1 fire extinguisher which is fully charged. Facility has small supply of PPE. LPA discussed with Administrator importance of maintaining 30 days supply of PPE. Facility has 2 refrigerators with ample food supply. Facility has required Emergency Disaster Plan posted on wall. Facility has a secured location for resident medication and files. Facility has 30 days supply of medications for Residents. LPA reviewed Residents files during visit. Residents emergency contact information is current. Facility has outside designated visitation area.

An exit interview was conducted with Administrator Victor Mckenzie and a copy of report was left at facility.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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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