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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300612904
Report Date: 11/08/2021
Date Signed: 11/08/2021 01:45:15 PM

Document Has Been Signed on 11/08/2021 01:45 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:ADELINE GUEST HOMEFACILITY NUMBER:
300612904
ADMINISTRATOR:ADELINA MONCERAFACILITY TYPE:
740
ADDRESS:741 N. EAST STREETTELEPHONE:
(714) 996-0568
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 6CENSUS: 3DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Regie BanggalatTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Norman Woodridge conducted a Covid-19 Annual Inspection at the facility. Upon arrival, LPA met with staff 1 (S1), informed S1 of the purpose of the visit, and conducted a tour of the inside and outside of the facility, common areas, kitchen, bedrooms, bathrooms, and garage.

LPA and administrator, Regie Banggalat, discussed and observed the following:

LPA observed a 2-day supply of perishables and a 7-day supply of nonperishables. LPA observed PPE supply and Covid-19 signage throughout the facility. Hallways and walkways were free from obstruction. LPA observed liquid hand soap and paper towels in restrooms. LPA reviewed temperature check log for residents, staff roster, and client roster. LPA provided technical assistance on staff screening and documentation. Facility requested additional PPE from Regional Office. LPA advised that a request will be made, and AD would be followed up with.

LPA issued a technical assistance for the facility failing to lock a cabinet with cleaning supplies. Facility immediately corrected deficiency. AD advised facility will provide in service training for staff regarding ensuring cabinets are locked and provide LPA with proof of training by Friday, November 12, 2021.

An exit interview was conducted with AD and a copy of this report was provided.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Norman Woodridge
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2021
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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