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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003390
Report Date: 03/28/2022
Date Signed: 03/28/2022 01:31:46 PM


Document Has Been Signed on 03/28/2022 01:31 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:ANAHEIM VILLA GUEST HOMEFACILITY NUMBER:
306003390
ADMINISTRATOR:LEO ALVIDERAFACILITY TYPE:
740
ADDRESS:1439 W. KIAMA PLACETELEPHONE:
(714) 758-3826
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY:6CENSUS: 5DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Leo Alvidera,
Maricel Alvidera		TIME COMPLETED:
02:00 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 LPA explained the nature of the visit. Maricel and Leo Alvidera, Administrators arrived shortly after and met with LPA.

LPA Martinez accompanied by Administrator began the tour of the inside and outside of the facility. There are five residents in care and there are no active covid-19 cases in facility. LPA observed a check in station upon entry to the facility. Facility is taking temperature daily and documenting the results. LPA observed two residents in living room watching TV and remainder of residents in their bedrooms. 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 throughout the facility. All restrooms observed to have ample supply of soap and appeared to be clean. LPA inspected residents’ bedrooms and they appeared to be clean and sanitary. All bedrooms observed to have all required components. LPA observed the emergency disaster and evacuation plan. Facility has the back-up emergency food and water supply as well as PPE supplies in the facility. LPA toured the outside of the facility and observed a shaded seating area for resident’s enjoyment. LPA was advised that staff and residents have had their Covid booster shots. The facility has completed the LIC808 Mitigation Plan. The plan was reviewed and approved by the Department on July 21, 2021.

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

This report was reviewed with the facility representatives 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: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
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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