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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306002211
Report Date:
08/30/2021
Date Signed:
08/30/2021 11:38:48 AM
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:
PRECIOUS MOMENTS GUEST HOME
FACILITY NUMBER:
306002211
ADMINISTRATOR:
DIANE PACA
FACILITY TYPE:
740
ADDRESS:
1416 BIRCHMONT DR.
TELEPHONE:
(714) 999-6644
CITY:
ANAHEIM
STATE:
CA
ZIP CODE:
92801
CAPACITY:
6
CENSUS:
DATE:
08/30/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:16 AM
MET WITH:
Diane Paca
TIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual mitigation inspection. LPA was greeted and granted entry by Administrator Diane Paca. Diane Paca's Administrator's Certificate expires 8/2/2022. LPA and Administrator toured the facility. LPA observed that the resident room had the required furnishings. Smoke detectors tested operational. The kitchen was clean and organized. LPA observed 2 day perishable and 7 day non-perishable food supply on hand. Bathrooms were clean and operational. LPA toured the outside of the facility. LPA observed the pool is fenced and secured. The exit gate is operational. The covered patio has a seating area for residents. LPA inspected the first aid kit which had all the required elements. LPA observed medication is kept locked in a cabinet. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME:
Luz Adams
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Joseph Alejandre
TELEPHONE:
(951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE:
08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/30/2021
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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