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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001989
Report Date: 08/31/2021
Date Signed: 08/31/2021 10:49:27 AM

Document Has Been Signed on 08/31/2021 10:49 AM - 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:CARING VILLAGEFACILITY NUMBER:
306001989
ADMINISTRATOR:MICHELLE DOMINGOFACILITY TYPE:
735
ADDRESS:8912 W. KATELLATELEPHONE:
(714) 484-6524
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 49CENSUS: 42DATE:
08/31/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Michelle Domingo, AdministratorTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA arrived at the facility was greeted by the receptionist and advised of the visit. LPA met with Michelle Domingo, Administrator and explained the nature of today's visit.

LPA Martinez accompanied by Michelle Domingo, Administrator began the tour of the facility. There are 42 clients in care. LPA observed several clients throughout the facility and in their bedrooms. Clients appeared clean and well taken care of. LPA observed a check in station in the main receptionist with temperature checks, sanitizer and covid questioner. LPA observed required postings and covid precautionary postings throughout the facility as well as hand washing signs in the bathrooms. All bathrooms appeared to be clean and sanitized. All bedrooms appeared clean and sanitary with all required components. LPA observed facility being cleaned/sanitized throughout the facility. Facility is taking covid-19 precautionary measures on a daily basis. There is a minimum of one week non-perishables foods and two days of perishables food available. LPA observed the storage room with emergency food supply, water, and PPE supplies. First aid kits are stored in the main receptionist area, Administrator's office, and in kitchen. LPA observed facility has a signed approved LIC808 Mitigation plan available for review.

Based on the observations made during today's visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted, this report was reviewed with Administrator and a copy of this report was provided and left at the facility.


SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2021
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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