306000332-5-1-2025-22-AS-HGOH-DG9THW-20250501144525

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306000332
Report Date: 05/01/2025
Date Signed: 05/01/2025 02:46:03 PM

Document Has Been Signed on 05/01/2025 02:46 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	PILGRIM'S FAITH CARE HOME		FACILITY NUMBER:	306000332
ADMINISTRATOR/ DIRECTOR:	VIVIAN JONAH S. RUEDAS		FACILITY TYPE:	740
ADDRESS:	8380 MONTANA AVENUE		TELEPHONE:	(714) 562-0190
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90621
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	05/01/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Vivien Ruedas		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct an unannounced visit to complete the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Licensee Vivien Reudas and explained the nature of the visit. The facility currently has no residents.

The facility is a single story home with one staff bedroom, four resident bedrooms, one staff bathroom, one resident bathroom, living room, kitchen, backyard and attached two car garage. The licensee currently resides at the residence. The kitchen is free of debris and appears to be clean. LPA observed knives to be locked in a drawer next to the stove making them inaccessible to residents. LPA observed a two day perishable and seven day non-perishable food supply. LPA observed the garage to be locked made inaccessible to residents. LPA observed toxins to be locked in the garage making them inaccessible to residents. LPA observed the required departmental postings in the facility. LPA inspected the locked centrally stored medication cabinet to be located in the kitchen making it inaccessible to residents. LPA observed the resident bedroom to have the required components and furnishings. LPA observed the resident bathroom to have all the required components. LPA observed the water to be at 115.8 degrees Fahrenheit in the resident bathroom. LPA observed that the facility has a clean supply of linens for resident use. LPA observed the backyard to be free of obstructions and debris. LPA observed a shaded seating area in the backyard for resident use.

LPA tested the fire and carbon monoxide detectors and they were found to be operational. LPA observed a fire extinguisher in the kitchen that was charged and had a service date of July 23, 2024. LPA observed activities for client enjoyment in the living room. LPA reviewed administrators certificate to have an expiration date of January 1, 2027. All staff present have been background cleared and are associated to the facility.

continue on 809-C

Armando J Lucero	TELEPHONE: (714) 703-2866
Hanna Gough	TELEPHONE: 714-627-6076
	DATE: 05/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PILGRIM'S FAITH CARE HOME	FACILITY NUMBER: 306000332
	VISIT DATE: 05/01/2025

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Licensee informed LPA that they are not sure if they want to stay open but will be doing updates to the facility in the meantime. LPA informed licensee that they need to call the department before retaining their first resident. The last resident left the facility on February 1, 2025 and moved to another facility with the help of Licensee Vivien.

Based on today’s observations made during the inspection no citations were noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Licensee Vivien Reudas and a copy of this report was given at the time of the inspection.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2866
LICENSING EVALUATOR NAME: Hanna Gough	TELEPHONE: 714-627-6076
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC809 (FAS) - (06/04)

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