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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306003566
Report Date:
10/08/2020
Date Signed:
02/08/2024 08:44:18 AM
Document Has Been Signed on
02/08/2024 08:44 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 & INLAND A/SC
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
FRANCEL GUEST HOME II
FACILITY NUMBER:
306003566
ADMINISTRATOR:
FRANCISCO BALISI
FACILITY TYPE:
740
ADDRESS:
9441 HOUSTON AVENUE
TELEPHONE:
(714) 844-2527
CITY:
ANAHEIM
STATE:
CA
ZIP CODE:
92801
CAPACITY:
14
CENSUS:
DATE:
10/08/2020
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:03 PM
MET WITH:
Francisco Balisi
TIME COMPLETED:
01:27 PM
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Licensing Program Analyst (LPA) Joseph Alejandre called the facility via Iphone due to Covid-19 precautionary measures and spoke with Administrator Francisco Balisi concerning a death report the Agency received on 10/5/2020. LPA explained the reason for the call. LPA verified with the Administrator that client C1 passed away on 9/26/2020 around 8:01 am at the facility. A staff member found the client on the floor and immediately called 911. The paramedics could not save C1. The facility notified the responsible party and the Regional Center. The police were called because C1 had passed away. No action was taken. The exact cause of death is unknown. A coroner's report is pending. The administrator reported that they have not received any reports from the police or the coroner. An exit interview was conducted and a copy of this report was provided via email.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Joseph Alejandre
TELEPHONE:
(951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE:
10/14/2020
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/14/2020
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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