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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306003675
Report Date:
07/23/2021
Date Signed:
07/23/2021 09:12:29 AM
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:
CHARLOU GUEST HOME IV
FACILITY NUMBER:
306003675
ADMINISTRATOR:
DOLORES BENEDICTO
FACILITY TYPE:
740
ADDRESS:
247 S. BRENTWOOD PLACE
TELEPHONE:
(714) 491-1108
CITY:
ANAHEIM
STATE:
CA
ZIP CODE:
92804
CAPACITY:
6
CENSUS:
4
DATE:
07/23/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
07:47 AM
MET WITH:
Paula Estrada Valencia
TIME COMPLETED:
09:11 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jim August conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Caregiver Paula Estrada Valencia and explained the reason for the visit.
LPA August toured the facility. There are four residents residing in the facility and no active covid-19 cases. LPA observed four residents on site. All residents appeared clean and well taken care of. LPA observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Resident bedrooms appeared clean and sanitary and had all required components. Facility is taking residents temperatures daily and documenting results. LPA observed the emergency disaster and evacuation plans. Facility has back-up emergency food and water supply as well as PPE supplies. Facility has completed the LIC808 Mitigation Plan.
No citations noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME:
Sheila Santos
TELEPHONE:
(714) 703-2857
LICENSING EVALUATOR NAME:
James August
TELEPHONE:
714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE:
07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/23/2021
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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