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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000523
Report Date: 02/22/2022
Date Signed: 02/22/2022 11:32:43 AM

Document Has Been Signed on 02/22/2022 11:32 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:ANAHEIM GUEST HOMEFACILITY NUMBER:
306000523
ADMINISTRATOR:EVELYN ENCARNACIONFACILITY TYPE:
735
ADDRESS:127 W. HILL PLTELEPHONE:
(714) 776-3075
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 40CENSUS: 40DATE:
02/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Evelyn Encarnacion, AdministratorTIME COMPLETED:
11:47 AM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required inspection visit. LPA was greeted and granted entry into the facility by Evelyn Encarnacion, Administrator. LPA met with Administrator and explained the nature of the visit.

LPA accompanied by the Administrator began the tour of the inside and outside of the facility. The facility currently has 40 clients in care. LPA observed various clients throughout the facility while conducting inspection. LPA observed staff cleaning and sanitizing the facility. Facility staff screens all visitors to the facility and LPA observed the screening station in the entrance of the facilities office. Facility keeps documentation in regard to covid for all the staff and clients. LPA observed the facility has covid precautionary postings throughout the facility as well as required department postings. Facility has an active covid-19 prevention plan in place for the safety of clients in care. LPA observed the food supply, emergency food supply and water supply in the facility. Facility has PPE and cleaning supplies. Facility has sanitation precaution in place throughout the facility and in all common spaces. LPA toured the outside of the facility and observed various seating areas for the clients. Areas are used for outdoor visitations as well. Facility has a plan for covid testing clients and staff as well as a plan for isolation as needed. LPA was advised that facility has completed staff and client covid booster shots. The facility has completed the LIC808 Mitigation plan, the Department approved the plan on April 27, 2021.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Administrator and a copy of this report was provided to the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
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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