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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001518
Report Date: 09/29/2021
Date Signed: 09/29/2021 01:15:48 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:A PIECE OF HEAVENFACILITY NUMBER:
306001518
ADMINISTRATOR:CELIA RODRIGUEZFACILITY TYPE:
740
ADDRESS:23191 TULIP STREETTELEPHONE:
(949) 586-9235
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 6DATE:
09/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Daniel Cabrera TIME COMPLETED:
01:20 PM
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This unannounced Covid-19 annual inspection is being conducted by Licensing Program Analyst (LPA) Norman Woodridge for the purpose of conducting an Annual Inspection. LPA met with Administrators (AD) Daniel Cabrera and Celia Rodriguez. LPA informed administrators of the purpose of the visit. LPA completed screening procedure and was granted entry into the building.

LPA observed the following:

During the inspection, LPA and staff 1 (S1) conducted a tour of the inside and outside of the facility, common areas, resident rooms, garage, and kitchen. Six residents were at the facility and all residents were doing well. Client rooms were clean and organized. LPA observed a 2-day supply of perishables and a 7-day supply of nonperishables. LPA observed hallways and walkways that were free of obstruction. LPA and administrators discussed Provider Information Notice 21-38-ASC: Update Guidance for the Use of Masks, Surgical Masks, Respirators Related to Coronavirus Disease 2019 (COVID-19). LPAs also discussed Covid-19 Mitigation Plan. A copy of PIN 21-38-ASC was given administrator.

No deficiencies were noted during the inspection.

An exit interview was conducted with ADs and a copy of this report was provided.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Norman WoodridgeTELEPHONE: (714) 703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
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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