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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
300612904
Report Date:
08/06/2024
Date Signed:
08/06/2024 11:16:18 AM
Document Has Been Signed on
08/06/2024 11:16 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
CCLD Regional Office
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
ADELINE GUEST HOME
FACILITY NUMBER:
300612904
ADMINISTRATOR/
DIRECTOR:
ADELINA MONCERA
FACILITY TYPE:
740
ADDRESS:
741 N. EAST STREET
TELEPHONE:
(714) 996-0568
CITY:
ANAHEIM
STATE:
CA
ZIP CODE:
92805
CAPACITY:
6
CENSUS:
4
DATE:
08/06/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:
Jen Jimenez
TIME VISIT/
INSPECTION COMPLETED:
11:35 AM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Samer Haddadin conducted an unannounced Plan of Correction (POC) visit to follow up on deficiencies cited on 08/02/2024. LPAs were greeted and granted entry into the facility and explained the reason for the visit.
Deficiency cited under Title 22 Regulation 87468.1(a)(1) pertaining to Personal Rights has NOT been cleared. Facility did not provide proof of correction. Licensee has NOT complied with the POC. CIVIL PENALTY ASSESSED.
Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME
:
Alisa Ortiz
LICENSING EVALUATOR NAME
:
Kimberly Lyman
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/06/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/06/2024
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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