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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000106
Report Date: 10/03/2023
Date Signed: 10/03/2023 05:07:21 PM

Document Has Been Signed on 10/03/2023 05:07 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:PROMISES GUEST VILLAGEFACILITY NUMBER:
306000106
ADMINISTRATOR:DANTE ENCARNACIONFACILITY TYPE:
735
ADDRESS:1315-1321 ANAHEIM BLVD.TELEPHONE:
(714) 774-1544
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 40CENSUS: 40DATE:
10/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:46 PM
MET WITH:Dante EncarnacionTIME COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced case management visit. LPA met with Administrator Dante Encarnacion and explained the reason for the visit. During the 10-day complaint visit (see complaint # 22-AS-20231003113624) LPA Alejandre observed the following. Facility is a one story building with 28 bedrooms and 8 bathrooms, kitchen, laundry room, dining room, living room, storage garage and office. LPA observed insects in the kitchen behind a waste receptacle located by the West kitchen wall. LPA observed the kitchen floor was dirty. There is a central courtyard with a covered seating area. During the visit one of the clients was not feeling well. Staff called 911 for the client. Client was evaluated and then transported to the hospital for treatment. LPA spoke with 10 clients during the visit who all stated they were doing well. LPA observed all 8 bathrooms were operational. LPA consulted with Administrator concerning reporting requirements and CCR 80087 Building and Grounds. Based on the observations made from today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was provided as well as Appeal Rights.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2023
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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Document Has Been Signed on 10/03/2023 05:07 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 10/03/2023 at 04:26 PM
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: PROMISES GUEST VILLAGE
FACILITY NUMBER: 306000106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2023
Section Cited
CCR
80087(a)(2)

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The licensee shall take measures to keep the facility free of flies and other insects.
This requirement is not being met as evidenced by, LPA observed insects in the kitchen behind a waste receptacle located by the West kitchen wall.
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Licensee agrees to have an exterminator treat the facility to eliminate all insects. Licensee to forward proof of service to LPA by 10/10/23.
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This poses an immediate Health and Safety risk to clients in care.
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Type B
10/11/2023
Section Cited
CCR80087(a)

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The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not being met as evidenced by,
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Licensee agrees to have and keep the facility clean at all times. Licensee agrees to keep a cleaning schedule and log to ensure all areas of the facility are maintained properly. Licensee to forward proof of correction to LPA by POC due date.
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 LPA observed the kitchen floor was dirty. This poses a potential health and safety risk to clients in care.
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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.
SUPERVISOR'S NAME:Luz Adams
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023


LIC809 (FAS) - (06/04)
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