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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000833
Report Date: 09/21/2021
Date Signed: 09/21/2021 02:39:24 PM

Document Has Been Signed on 09/21/2021 02:39 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:MISSY'S GUEST HOMEFACILITY NUMBER:
306000833
ADMINISTRATOR:RODOLFO G. MENDOZAFACILITY TYPE:
735
ADDRESS:9531 BIXBY AVENUETELEPHONE:
(714) 534-7571
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6CENSUS: 2DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Administrator, Rodolfo MendozaTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted, granted entry into the facility and explained the reason for the visit.

During the visit LPA toured the facility with Administrators Rodolfo Mendoza and Maria Luisa Mendoza. Facility is a 5 bedroom,(3 client bedrooms and 2 staff bedrooms) and 2 1/2 bathrooms single story home. There are 2 Clients in care. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring March 4, 2022. LPA toured all Clients rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper and paper towels. Restrooms had proper hand washing signs. Clients were observed relaxing in outside patio. Facility has 1 fire extinguisher which is fully charged. Facility has ample supply of PPE. Facility has 2 refrigerators and pantry with ample food supply. LPA observed facility has emergency food and water supply. Facility has required Emergency Disaster Plan posted. Facility has a secured location for client medication and files. Facility has 30 days supply of medications for clients. LPA reviewed clients files during visit. Clients emergency contact information and Physicians reports are current. Facility has designated visitation area.

No deficiencies noted during todays visit. An exit interview was conducted with Administrator and a copy of report was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2021
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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