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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002818
Report Date: 08/19/2021
Date Signed: 09/01/2021 07:27:25 PM

Document Has Been Signed on 09/01/2021 07:27 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:GLORIOUS HOME #3FACILITY NUMBER:
306002818
ADMINISTRATOR:DELAGNEAU, CHESTERFACILITY TYPE:
740
ADDRESS:24726 ARGUS DRIVETELEPHONE:
(949) 581-1039
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Chester DelagneauTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Administrator Chester Delagneau and Caregiver Laura Alvarez. The focus of the visit was Infection Control. During the visit LPA toured the facility and the following was observed:

Covid signage was posted at the front entrance of facility with a sanitization station. LPA's temperature was taken upon arrival. A sign in sheet will need to be made available. Facility has required Department postings. Administrator Certificate for Chester Delagneau expires on 1/3/23. Mr. Delagneau was also reminded that all staff need to be associated through Guardian. Civil penalties will be issued if not completed. LPA toured all resident rooms. Rooms were clean and sanitary. All restrooms observed contained soap, paper towels and toilet paper. Hand sanitizer, soap, wipes and gloves were present. The Licensee has at least a 30 day supply of PPE. LPA observed an outside visitation area with ample shading. Residents were observed outside on the patio and resting in their rooms. Licensee has required Mitigation plan and Emergency Disaster Plan. LPA observed emergency food and water supply. Facility has a secured location for resident medication and files.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of mask wearing and handwashing for staff. Administrator is reminded to review PIN 20-17.2-ASC in regards to Visitation, dining, Group Activities, Non-essential services, Outings, New Admissions and Entertainment. as well as PIN 21-32-ASC Updated Facility Staff Testing and Masking Guidelines. No deficiencies noted during visit. An exit interview was conducted and a copy of this report was provided to Chester Delagneau. .
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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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