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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003049
Report Date: 04/14/2022
Date Signed: 04/15/2022 08:14:01 AM

Document Has Been Signed on 04/15/2022 08:14 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:CEDAR GUEST HOMEFACILITY NUMBER:
306003049
ADMINISTRATOR:LIGAYA GARCIANOFACILITY TYPE:
735
ADDRESS:8667 CEDAR DRIVETELEPHONE:
(714) 484-0227
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 5DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Caregiver Angela Farro/ Assistant Admin Yvellete TantiadoAdministrator Ligaya GarcianoTIME COMPLETED:
11:20 AM
NARRATIVE
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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 Angela Farro and explained the reason for the visit. Assistant Administrator Yvellete Tantiado arrived at 9:48AM and Administrator Ligaya Garciano arrived at 10:07AM.

At 9:15AM LPA toured the facility with Caregiver Angela Farro .Facility is a 4 bedroom, 2 bathroom, single story home with an attached garage. Facility has 2 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/ questionnaire. Facility takes client and staff temperatures daily and documents. Facility has covid precaution postings. LPA observed 7 day supply of emergency food and a 24 pack 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 a 4 week supply of PPE. All staff and clients are vaccinated for Covid-19. LPA reviewed all client files and all contained required documentation including updated emergency information.


Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed and a copy of 809, 809-D, LIC 421BG and appeal rights were provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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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Document Has Been Signed on 04/15/2022 08:14 AM - It Cannot Be Edited


Created By: Andrea Mendivil On 04/14/2022 at 10:41 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CEDAR GUEST HOME
FACILITY NUMBER: 306003049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
80019(e)(2)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 80019(f)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based observation and record review, the licensee did not comply with the section cited above as assistant administrator is not associated with facility.This poses an immediate health and safety risk to persons in care.
POC Due Date: 04/15/2022
Plan of Correction
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Adminstrator to associate Assistant Administrator and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022


LIC809 (FAS) - (06/04)
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