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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003432
Report Date: 01/16/2024
Date Signed: 01/16/2024 11:50:22 AM

Document Has Been Signed on 01/16/2024 11:50 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:EMBASSY RESIDENTAL CAREFACILITY NUMBER:
306003432
ADMINISTRATOR:CORA KONFACILITY TYPE:
735
ADDRESS:1809 W. EMBASSY AVENUETELEPHONE:
(714) 758-3677
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 4DATE:
01/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Eduardo EleazarTIME COMPLETED:
12:10 PM
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Licensing Program Analysts (LPAs) Ruth Martinez and Jenifer Tirre are conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by staff. LPA met with Eduardo Eleazar, caregiver and LPA explained the nature of the visit.

Four clients reside at this facility, LPA was informed there are clients were out in the community. At the time of our visit one client was at the facility. LPA accompanied by a caregiver began the tour of the inside and outside of the facility. LPA observed required department postings posted on the wall of facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in the kitchen. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care. LPA inspected the bathroom and LPA measured the hot water temperature which measured 108.5 Fahrenheit degrees. All bathrooms were observed to have a supply of soap, toilet paper and towels. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked underneath the kitchen sink and in the garage. The facility has an available clean supply of linens. LPA inspected client’s bedrooms which have sufficient lighting to ensure safety and comfort. All bedrooms were observed to have all the required components. Storage space is provided for clients in their bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there is shaded seating areas for client’s enjoyment. LPA observed a fire extinguisher with service date of August 30, 2023, in the kitchen. Fire drills are conducted every three months and LPA verified last Fire Drill was conducted on January 2, 2024. LPA began review of records. LPA reviewed four clients’ records. All the

Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: EMBASSY RESIDENTAL CARE
FACILITY NUMBER: 306003432
VISIT DATE: 01/16/2024
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required documentation was present and current in the client’s files reviewed. The facility P&I records were reviewed. LPA observed that an individual log is maintained for each client. All monies are accounted for and attached receipts for record keeping. LPA reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate.

Based on the observations 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 representative, and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC809 (FAS) - (06/04)
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