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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300612904
Report Date: 05/01/2025
Date Signed: 05/01/2025 02:07:23 PM

Document Has Been Signed on 05/01/2025 02:07 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/
DIRECTOR:		ADELINA MONCERAFACILITY TYPE:
740
ADDRESS:741 N. EAST STREETTELEPHONE:
(714) 996-0568
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 6CENSUS: 4DATE:
05/01/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:01 PM
MET WITH:Ruby Cruz- House Manager TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit in conjuction with complaint visit for complaint control # 22-AS-20250421115146. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit.

When LPA Mendivil arrived at the facility at 8:00am LPA observed a female and male in the facility. Before LPA Mendivil could ask who they were they left the facility. LPA Mendivil observed female in the kitchen standing over the kitchen sink doing dishes. LPA Mendivil observed the male answer the door.
LPA Mendivil questioned House Manager Ruby Cruz about the presence of the female and male and she stated they were supposed to "shadow" as caregivers today.

LPA Mendivil asked if they were associated to the facility as they were working when LPA Mendivil arrived and Ruby stated they were not associated to the facility yet.

Review of 4 out of 4 residents files revealed 3 residents are currently on hospice, the facility has a hospice waiver for 2. LPA Mendivil spoke with Licensee Adelina Moncera via telephone and she stated she will email hospice waiver increase request by 05/02/2025.

Therefore based on observations and interviews the following is being cited per Title 22.
An exit interview was conducted and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Andrea Mendivil
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/01/2025 02:07 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 05/01/2025 at 10:26 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ADELINE GUEST HOME
FACILITY NUMBER: 300612904

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/02/2025
Section Cited
CCR
87411(g)(3)

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(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r)..
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Licensee to associate staff prior to employment, provide proof to LPA by POC due date
* An immediate civil penalty is being assessed
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This requirement was not met as evidence by 2 caregivers were present and working at the facility before completing being associated to the facility. This poses an immediate health and safety risks to persons in care.
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Type A
05/02/2025
Section Cited
CCR87632(a)(1)

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(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department.
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Licensee to send hospice waiver increase request to LPA by POC due date.
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(1)Specification of the maximum number of terminally ill residents which the facility wants to have at any one time. This requirement was not met as evidence by facility accepted a 3rd resident when they have a hospice waiver for 2 residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Andrea Mendivil
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2025


LIC809 (FAS) - (06/04)
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