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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000259
Report Date: 10/03/2022
Date Signed: 10/03/2022 12:02:44 PM

Document Has Been Signed on 10/03/2022 12:02 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:PACIFIC PLACE GUEST HOMEFACILITY NUMBER:
306000259
ADMINISTRATOR:L. GARCIANOFACILITY TYPE:
735
ADDRESS:1584 PACIFIC PLACETELEPHONE:
(714) 776-8130
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: 4DATE:
10/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:53 AM
MET WITH:Aurea Tiquia, Yvellete TantiadoTIME COMPLETED:
12:15 PM
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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.

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 10:53 AM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed two clients in care and two staff members on duty. LPA toured the interior and exterior portions of the facility. There were three shared client rooms and one caregiver room. Client rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors and carbon monoxide alarms were tested to be operational. Bathroom was observed to be in good repair and hot water was measured at 112.8 degrees Fahrenheit. 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. Backyard had several fruit trees in good condition. Facility offers a 2-car garage mainly used for storage with an extra refrigerator and operational washer and dryer. Kitchen was in good repair. Medications, toxins and sharps were locked and kept away from clients. LPA did noticed a light in the kitchen was not operation. Kitchen did have adequate lighting. Assistant will have light replaced. LPA Tapia reviewed the COVID 19 mitigation plan and the emergency disaster plan of the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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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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: PACIFIC PLACE GUEST HOME
FACILITY NUMBER: 306000259
VISIT DATE: 10/03/2022
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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 one advisory was issued.

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

DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022
LIC809 (FAS) - (06/04)
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