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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000523
Report Date: 02/20/2025
Date Signed: 02/20/2025 03:19:10 PM

Document Has Been Signed on 02/20/2025 03:19 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/
DIRECTOR:		EVELYN ENCARNACIONFACILITY TYPE:
735
ADDRESS:127 W. HILL PLTELEPHONE:
(714) 776-3075
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 40CENSUS: 38DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Evelyn EncarnacionTIME VISIT/
INSPECTION COMPLETED:
03:35 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 met with 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. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. The courtyard has a shaded sitting area. LPA observed clients socializing in common areas and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, and faucets and toilets were operational. Water temperature tested between 106.5-120.7 degrees Fahrenheit.

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 are located in every facility hallway and were observed to be fully charged with a service tag dated July 1, 2024. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to clients. Medication was observed to be centrally stored in a locked medication cart.

Assistant Administrator Jerel Encarnacion arrived at approximately 1:00 p.m. to assist with the inspection. LPA reviewed six client files and three staff files. Two of six client medical assessments did not include results of examination for TB; a Deficiency was cited on today’s date. LPA interviewed six clients and three staff.

Based on the observations made during today’s inspection, one deficiency is 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: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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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Document Has Been Signed on 02/20/2025 03:19 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 02/20/2025 at 02:59 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: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two of six client files, which poses a potential health risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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AD stated TB examination results will be obtained and proof provided via email by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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