<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002287
Report Date: 05/31/2022
Date Signed: 05/31/2022 06:05:17 PM


Document Has Been Signed on 05/31/2022 06:05 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:LORRAINE GUEST HOMEFACILITY NUMBER:
306002287
ADMINISTRATOR:TERESITA LOZANOFACILITY TYPE:
740
ADDRESS:5742 BELLE AVENUETELEPHONE:
(714) 828-6640
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY:6CENSUS: 5DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:36 PM
MET WITH:Care staff Joy Espanol TIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Care staff Joy Espanol and explained the reason for the visit.

LPA Frank toured the facility. There are 5 residents residing in the facility and no active COVID-19 cases. LPA observed 5 residents on site appeared clean and well taken care of. LPA observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Resident bedrooms appeared clean and sanitary and had all confirmed food supply: 2 day supply of perishables and 7 day supply of
non-perishable food is available for the number of residents present. Hygiene supplies and supply of linen
were observed in quantities for the number of residents in care. LPA observed locked areas for toxins and
hazardous items. Medication were observed locked in cabinet.
LPA observed the facility to be clean and in good repair.
LPA Frank reviewed : 1.) Emergency Disaster Plan (LIC610E); 2 ) LIC 9020A Client Roster; LIC 808)
Mitigation Plan and 3) Current Liability Insurance, Designation of Administrative Responsibility (LIC308) and
Personnel Report (LIC500);
Based on the observations made during today’s visit, no deficiencies are being cited in area inspected.
This report was discussed with the facility representative and a copy was provided.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Shobhana FrankTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1