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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000106
Report Date: 10/18/2021
Date Signed: 10/18/2021 02:59:29 PM

Document Has Been Signed on 10/18/2021 02:59 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: 39DATE:
10/18/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Dante Encarnacion TIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) Norman Woodridge and Jenifer Tirre conducted a case management visit at the facility to follow up regarding incident reported on Thursday, October 14, 2021. Upon arrival, LPAs informed Staff 1 (S1) of the purpose of the visit and were granted entry into the building. LPAs and S1 conducted a tour of the inside and outside of the facility, common areas, resident rooms, bathrooms, and kitchen.

LPAs met with administrator, Dante Encarnacion (AD) and observed the following:

LPAs observed clients engaging in activities and a welfare check was conducted. LPAs observed a 2-day supply of perishables and a 7-day supply of nonperishables. LPAs observed sufficient PPE and a supply of hygiene products for clients including shampoo, toothpaste, and shaving cream. LPAs checked client bedrooms and bathrooms. LPAs reviewed files, provided technical assistance, and interviewed AD about the incident reported on October 14, 2021. LPAs secured staff roster, client roster, physician reports, and a discharge report.

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: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2021
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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