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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004196
Report Date: 02/28/2023
Date Signed: 02/28/2023 03:45:33 PM

Document Has Been Signed on 02/28/2023 03:45 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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PLEASANT CARE HOME, THEFACILITY NUMBER:
306004196
ADMINISTRATOR:LOMBOS, DOMINIC L.FACILITY TYPE:
735
ADDRESS:10220 CARLOTTA AVENUETELEPHONE:
(714) 235-4865
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 4DATE:
02/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:06 PM
MET WITH:Henry Crodue, caregiver
Dominic Lombos, administrator (via phone)		TIME COMPLETED:
04:00 PM
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On this day, Licensing Program Analyst (LPA) made an unannounced visit to the facility for the purpose of conducting a case management visit related to allegations being investigated at God Blessing Home - 306003987. LPA was greeted and granted entry by caregiving staff after stating the purpose of the visit. Administrator Dominic Lombos was notified and spoke with LPA via telephone.

Staff confirm that client C1 was recently relocated from the facility listed above a few weeks prior to the visit.

Client C1 is observed relaxing in his bedroom. LPA interviewed client C1 who was shown to be alert and oriented and able to answer all questions asked.

LPA conducted a brief interview with facility staff and facility administrator regarding client C1's transfer as well.

No deficiencies cited per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2023
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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