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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000523
Report Date: 02/07/2023
Date Signed: 02/07/2023 10:23:34 AM

Document Has Been Signed on 02/07/2023 10:23 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
ORANGE & INLAND A/SC, 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: 39DATE:
02/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:TIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA arrived at the facility was greeted by Evelyn Encarnacion, Administrator and explained the nature of the visit.

LPA Martinez accompanied by Administrator began the tour of the inside and outside of the facility. There are 39 clients in care and there are no active covid cases in the facility. Upon entry to the facility LPA observed several clients throughout the courtyard of the facility. There is a sign-in procedure in place and hand sanitize for use. LPA observed required department postings and covid precautionary postings throughout the facility. The facility has an approved Mitigation plan on file with CCLD. Facility has required Emergency Disaster Plan posted. Facility bathrooms observed to have a supply of soap, toilet paper and paper towels. LPA observed the bathrooms being cleaned while conducting the tour. LPA toured random client bedrooms; all bedrooms observed to have all the required components. The facility is equipped with sufficient hand hygiene supplies, cleaning and disinfecting provisions. The facility has an emergency food and water supply. The facility has a two day supply of perishable and seven day supply of non-perishable foods available. Personal protective equipment (PPE) supply is available, there is a 30 day supply on hand. Facility has a secure location for client’s medication, and it was observed there was a 30 day supply of medication for clients. LPA toured the outside of the facility and an observed seating throughout the courtyard for client’s use.

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

This report was reviewed with the Administrator and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2023
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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