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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001308
Report Date: 08/17/2021
Date Signed: 08/17/2021 03:02:22 PM

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:GOOD SAMARITAN GUEST HOME IVFACILITY NUMBER:
306001308
ADMINISTRATOR:CAMBIO, SUSAN & LEONARDFACILITY TYPE:
740
ADDRESS:26972 VIA GRANDETELEPHONE:
(949) 367-1806
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Adriana Castro Tapia and Leo CambioTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Adriana Castro Tapia and explained the reason for the visit. Licensee Leo Cambio arrived during visit.

At 9:45 AM, LPA toured the facility with Licensee Cambio. Facility has 5 residents during today's visit. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident's rooms had the required elements as well as restrooms stocked with soap/ sanitizer. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility takes resident temperatures daily. Facility has covid precaution postings as well as all required department postings. Facility has completed the mitigation plan and the plan has been approved. LPA observed adequate emergency food supply as well as the first aid kit which contained all required items. Facility has all items of PPE on site. LPA toured the outside grounds and observed ample shaded outside visitation areas. Exit gate is unlocked and self latching. LPA observed the locked medication storage area. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. All staff and residents are vaccinated for Covid-19. LPA reviewed all resident files and all contained emergency information.

LPA consulted with Licensee regarding the importance of documenting temperatures taken daily.

No deficiencies noted during today's visit.

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
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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