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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002818
Report Date: 07/29/2022
Date Signed: 07/29/2022 03:30:20 PM


Document Has Been Signed on 07/29/2022 03:30 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: 3DATE:
07/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Chester Delagneau, Administrator
Bibiana Saldivar, caregiver		TIME COMPLETED:
04:00 PM
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On 07/29/2022 at 2:30pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by Bibiana Salvidar, caregiver after explaining the purpose of the visit. Staff present called Chester Delagneau, Administrator to notify him of the visit. Administrator arrived later to assist with the visit.

At approximately 3:00pm, LPA accompanied by Administrator toured the inside and outside of the facility. LPA observed a check-in station where visitor temperatures are being documented. There are currently three (3) residents in care, one (1) of which is receiving hospice care. Hospice records for resident have been reviewed during the visit. Residents are observed relaxing in the common areas or in their bedroom and appear clean and well taken care of. The four (4) bedrooms include all necessary components. Bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected.

Sharp instruments are stored in a kitchen cupboard with a functional magnetic lock. LPA observed a sufficient supply of food and water. A 30-day supply of medication is centrally stored and locked in a cupboard located in the dining room. Cleaning supplies are secured in the locked laundry room. LPA observed the facility has COVID-19 Precautions and all required department postings. Facility has an adequate supply of PPE. Fire extinguishers are operational and charged.
Staff present is adequately cleared and associated in Guardian. LPA toured the outside of the facility and observed it to be free of obstructions. LPA observes a shaded area with patio furniture used by residents and visitors. The perimeter gate is self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
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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