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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003585
Report Date: 12/21/2022
Date Signed: 12/21/2022 12:08:01 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/21/2022 12:08 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:CALIFORNIA GUEST HOME IIFACILITY NUMBER:
306003585
ADMINISTRATOR:LUMING GUSTAVEFACILITY TYPE:
740
ADDRESS:1150 N. HARDING STREETTELEPHONE:
7149234692
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY:6CENSUS: 0DATE:
12/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Gerald GustaveTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived at California Guest Home II to conduct an unannounced Required 1 Year Inspection. At 11:24am, Administrator (Admin) Gerald Gustave was informed the purposed of the visit via a telephone call. At 11:40am, Admin arrived at the facility, and LPA was granted entry. Admin indicated from a phone conversation that there were no residents residing at this facility. Admin was informed to contact Community Care Licensing (CCL) when facility is ready to accept new residents and/or of any changes to the license. The annual licensing fee has been paid in full on November 14, 2022 and was verified on a carbon copy of the duplicate check during this visit.

The facility is a single level structure and licensed for six non-ambulatory residents and has a hospice waiver for two. LPA toured the interior and exterior portions of the facility and confirmed no residents in care. The Administrator and his family are occupying the facility. LPA reiterated to Administrator Gerald Gustave to report to Community Care Licensing Division (CCLD) prior to accepting new residents in order to conduct a follow-up health and safety inspection.

For this visit, the facility was observed to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations.

LPA Cho conducted an exit interview with Administrator Gerald Gustave, and a copy of this report was provided during this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
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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