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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002211
Report Date: 08/30/2022
Date Signed: 08/30/2022 12:36:18 PM


Document Has Been Signed on 08/30/2022 12:36 PM - 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:PRECIOUS MOMENTS GUEST HOMEFACILITY NUMBER:
306002211
ADMINISTRATOR:DIANE PACAFACILITY TYPE:
740
ADDRESS:1416 BIRCHMONT DR.TELEPHONE:
(714) 999-6644
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:6CENSUS: 1DATE:
08/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Diane PacaTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was screened for symptoms of Covid-19 and granted entry. LPA explained the reason for the visit. LPA met with Administrator Diane Paca. LPA observed the PUB 475 poster sign next to the main entrance. The PUB 475 sign measured 8 1/2 by 11 inches. LPA and Administrator toured the facility. Facility has 7 bedrooms, living room, kitchen, 2 car garage and 3 bathrooms (1 bathroom is a powder room). LPA observed that the resident rooms had the required furnishings. Smoke detectors and Carbon Monoxide detector tested operational. Hot water measured 108.3 degrees Fahrenheit. The kitchen was clean and organized. LPA observed 2 day perishable and 7 day non-perishable food supply on hand. The kitchen stove lights unassisted. Bathrooms were clean and operational. Fire extinguisher is fully charged. 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. There is a small storage shed on the side of the house by the exit gate. The shed is kept locked and used for storage. LPA inspected the first aid kit which had all the required elements. LPA observed medication is kept locked in a cabinet. No obstacles or hazards observed. 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 AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022
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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