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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002855
Report Date: 04/18/2022
Date Signed: 04/18/2022 10:31:00 AM

Document Has Been Signed on 04/18/2022 10:31 AM - 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:LANEROSE HOMEFACILITY NUMBER:
306002855
ADMINISTRATOR:SUSAN A. BAGUEFACILITY TYPE:
735
ADDRESS:1238 S. WESTERN AVENUETELEPHONE:
(714) 821-0671
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 5DATE:
04/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:House Manager - Eduardo Arenas and Caregiver - Susan ArenasTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Susan Arenas and Eduardo Arenas and explained the reason for the visit.

At 9:08AM LPA toured the facility with Eduardo Arenas. Facility is a 6 bedroom, 3 bathroom, single story home with an attached garage. Facility has 3 clients present during today's visit. LPA observed clients relaxing in their respective bedrooms and facility. Facility appears clean and sanitary. All client rooms had the required elements as well as restrooms stocked with soap/ sanitizer. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility uses a handwritten sign in sheet. Facility takes client and staff temperatures daily and documents. Facility has covid precaution postings. LPA observed 1 container of emergency food and 3-24 packs of water. LPA observed locked medication drawer. Facility has a plan for covid testing clients and staff as needed as well as a plan for isolation. LPA observed an ample supply of PPE. Some staff and all clients are vaccinated for Covid-19. LPA reviewed all client files and all contained required documentation including updated emergency information.


No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2022
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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