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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000106
Report Date: 04/13/2022
Date Signed: 04/13/2022 11:09:41 AM

Document Has Been Signed on 04/13/2022 11:09 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: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:
04/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Dante EncarnacionTIME COMPLETED:
11:22 AM
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Licensing Program Analysts (LPAs) Claudia Gutierrez and Lydia Martinez made an unannounced visit for the purpose of following up on an Incident report received on 4/12/2022. Report is regarding an unexpected death on 04/08/22. Upon arrival LPAs were greeted by administrator (AD) Dante Encarnacion. LPAs explained the reason for the visit and were granted entry into the facility.

LPA Gutierrez reviewed Resident 1's (R1) physician's report dated 09/18/2020 and found that resident had a history of Hyperlipidemia, Hypertensive Chronic Kidney Disease, and Nicotine Dependance since date of admission 08/23/1995.

Per AD Anaheim Police Department spoke with R1's primary physician and determined death was of natural causes therefore report was not taken.

LPAs and AD took a tour of the facility and observed the following:

Residents were observed throughout the facility, in common areas, and outside in various sitting areas.

LPAs observed no health and safety violations at this time.

No deficiencies cited. LPAs conducted an exit interview and a copy of this report was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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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