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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001749
Report Date: 04/29/2021
Date Signed: 04/29/2021 02:45:50 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:ARVILINH HOME CAREFACILITY NUMBER:
306001749
ADMINISTRATOR:ARVIN BUMANGLAGFACILITY TYPE:
740
ADDRESS:9351 MELBA DRIVETELEPHONE:
(714) 643-9077
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:6CENSUS: 6DATE:
04/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator Arvin Bumanglag TIME COMPLETED:
03:00 PM
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As precautionary measures during the Coronavirus 2019 (COVID 19) pandemic, Licensing Program Analyst (LPA) Albert Marin conducted an unannounced case management via teleconference with Administrator Arvin Bumanglag. LPA stated the purpose of the visit.

At 10:31 AM of April 28, 2021, LPA Marin conducted an unannounced in person visit in the facility in relation to the complaint investigation. LPA was granted entry by Staff 1; and momentarily met with AD Bumanglag and stated the purpose of the visit. LPA observed five residents in the facility; and two care staff members. One resident was out for a medical appointment. LPA reviewed facility documents and medication procedures with AD Bumanglag. Due to technical issues, LPA was not able to leave a report. LPA exited the facility at 11:29 AM.

For this teleconference, LPA Marin discussed Health and Safety Code (HSC) Sections 1569.625, 1569.626 and 1569.69. LPA also reviewed with AD Bumanglag California Code of Regulations (CCR) Sections 87411, 87465, and 87463. LPA also reviewed the Provider Information Notices (PINs) 21-01-CCLD and 21-02-CCLD.

No citation has been issued at this time.

LPA Marin conducted a phone exit interview with AD Bumanglag. Copies of this report, Advisory Notes and HSC, CCR and PINs were provided via email. As agreed, AD will acknowledge their receipt.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021
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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