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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000523
Report Date: 02/28/2024
Date Signed: 02/28/2024 03:33:48 PM

Document Has Been Signed on 02/28/2024 03:33 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: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:
02/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Evelyn EncarnacionTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Administrator (AD) Evelyn Encarnacion and explained the purpose of the inspection.

During the inspection, LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen and observed the following:

This is a one-story apartment complex with 23 client bedrooms and 7 bathrooms. LPA observed client beds had linens and blankets. The courtyard has multiple shaded sitting areas. LPA observed clients in common areas, socializing and resting in their respective bedrooms. Bathroom faucets and toilets were operational. Water temperature tested between 118.0-118.4 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguishers were mounted on the wall along each facility hallway, and observed to be fully charged with service tag dated 7/10/23. Gas stove, microwave, washer, and dryer were all inspected. Sharps were observed locked in the kitchen. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication was observed to be locked. LPA reviewed six client files and three staff files. Two out of three staff files were unavailable for review. Per AD, they are unable to locate their file and another staff's file. AD was also unable to provide LPA with a copy of current AD certificate or documentation submitted for certification renewal. LPA interviewed six clients and staff present.

Based on the observations made during today’s inspection, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2024
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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Document Has Been Signed on 02/28/2024 03:33 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 02/28/2024 at 02:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANAHEIM GUEST HOME
FACILITY NUMBER: 306000523

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on AD interview and record review, the licensee did not comply with the section cited above, as AD was unable to provide LPA with a current AD certificate and was unable to provide any documentation regarding AD certificate renewal, which poses a potential personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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AD stated they would provide LPA with proof of documenation submitted for AD certificate renewal via email by POC date.
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on AD interview and record review, the licensee did not comply with the section cited above, as AD is unable to locate two personnel files, which poses a potential health and personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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AD stated records would be located and maintained, and a copy of the two personnel files would be provided to LPA via email by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024


LIC809 (FAS) - (06/04)
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