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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003954
Report Date: 06/23/2021
Date Signed: 06/23/2021 02:09:28 PM

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:PILGRIMS GUEST HOMEFACILITY NUMBER:
306003954
ADMINISTRATOR:NORMITA/JOSE VIBARFACILITY TYPE:
740
ADDRESS:8431 SANTA BERTA WAYTELEPHONE:
(714) 995-4020
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:6CENSUS: 4DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Normita Vibar, Administrator TIME COMPLETED:
02:15 PM
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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 Dolores Milco and explained the reason for the visit. Administrator Normita Vibar arrived shortly after.

LPA August toured the facility with Administrator Vibar. There are four clients residing in the facility and no active covid-19 cases. All clients and staff have been vaccinated. All clients 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. Client bedrooms appeared clean and sanitary and had all required components. Facility is taking client's temperatures daily and documenting results. LPA observed the emergency disaster and evacuation plans, as well as the LIC808 Covid Mitigation Plan. Facility has back-up emergency food and water supply. LPA observed PPE supplies.

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 SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James AugustTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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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