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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300613080
Report Date: 09/08/2022
Date Signed: 09/08/2022 11:38:07 AM

Document Has Been Signed on 09/08/2022 11:38 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:PINE HILL GUEST HOMEFACILITY NUMBER:
300613080
ADMINISTRATOR:LIGAYA GARCIANO & QUIZON,FACILITY TYPE:
735
ADDRESS:1341 S. WALNUT STREETTELEPHONE:
(714) 527-3408
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: 6DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Yvellete "Ivette" Tantiado, Mark GarcianoTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with Assistant Ivellete Tantiado and stated the purpose of this visit. Finance Officer Mark Garciano arrived after the inspection.

The facility is a single level structure and licensed for a capacity of six with two non-ambulatory. This facility offers care for the Developmentally Disabled.

At about 9:37 AM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed five clients in care and two staff members on duty. LPA toured the interior and exterior portions of the facility. There were two shared client rooms and two private client rooms. Client rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide, and auditory exit alarms were tested to be operational. Bathrooms 1 & 2 were observed to be in good repair and hot water was measured between 125.9 – 126.9 degrees Fahrenheit. LPA made staff aware of water temperature. Staff stated they have recently checked the water temperature and it was not that hot. LPA reviewed boiler and saw that it was at the lowest setting. Staff will have handyman review boiler and lower the temperature. LPA Tapia is aware of the unseasonably warm temperatures and the effect it can have on the water temperature. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements, cleaning supplies were inaccessible to clients in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. LPA did notice that a guava tree needed to be trimmed, a ladder and garden hose was out in the open. Staff was made aware of this and rolled up garden hose and removed ladder from clients in care. Facility offers a 2-car garage mainly used for storage with an extra refrigerator and operational washer and dryer. Medications and toxins where locked and kept away from clients.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PINE HILL GUEST HOME
FACILITY NUMBER: 300613080
VISIT DATE: 09/08/2022
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Kitchen was in good repair. LPA did notice a towel surrounding the bottom of the refrigerator. LPA asked staff what it was for and they stated the refrigerator sometimes leaks. LPA did not notice any leaks but did make staff aware of repair or possible replacement needed. LPA Tapia reviewed the COVID 19 mitigation plan and the emergency disaster plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed and three advisories were issued.

LPA Tapia conducted an exit interview with Assistant Ivellete Tantiado and copy of this report was explained and left in the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC809 (FAS) - (06/04)
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