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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002300
Report Date: 09/13/2021
Date Signed: 09/13/2021 02:16:36 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:CALIFORNIA GUEST HOMEFACILITY NUMBER:
306002300
ADMINISTRATOR:LUMING GUSTAVEFACILITY TYPE:
740
ADDRESS:2840 QUINCY AVE.TELEPHONE:
(714) 289-0827
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY:6CENSUS: 4DATE:
09/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Luming GustaveTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by caregiver and explained the nature of the visit. Luming Gustave, Administrator arrived shortly after and met with LPA.

LPA Martinez accompanied by caregiver toured the inside and outside of facility. There are fur residents in care and there are no active covid-19 cases. LPA observed four residents in living room watching television. All residents appeared to be clean and well taken care of. LPA observed required department postings, covid-19 precautionary postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA inspected residents’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. LPA observed a check in station in the main entry of the facility. Facility is taking residents and staff temperatures daily and documenting results. LPA observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water supply as well as PPE supplies. Facility is story stories and LPA verified no residents reside in the second floor. Residents do no have access to the second floor. LPA toured the outside of the facility and observed seating area for resident’s enjoyment. Facility has completed the LIC808 Mitigation plan and was approved on March 05, 2021.

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

This report was reviewed with Administrator and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
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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