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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004497
Report Date: 12/07/2021
Date Signed: 12/23/2021 08:44:28 AM

Document Has Been Signed on 12/23/2021 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ALENA'S GUEST HOMEFACILITY NUMBER:
306004497
ADMINISTRATOR:ANN A. RUEDASFACILITY TYPE:
735
ADDRESS:1242 N. LEWELLYN AVENUETELEPHONE:
(714) 925-5249
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 6CENSUS: 6DATE:
12/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Wilhelmina Bayona TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Norman Woodridge conducted a Covid-19 Annual Inspection at the facility. Upon arrival, LPA met with House Manager Wilhelmina Bayona, informed her of the purpose of the visit, and completed visitation log. LPA conducted a tour of the inside and outside of the facility, common areas, kitchen, bedrooms, bathrooms, and garage.

LPA discussed and observed the following:

LPA observed a 2-day supply of perishables and a 7-day supply of nonperishables. House Manager reported a PPE shortage at the facility. Hallways and walkways were free from obstruction. LPA observed Covid-19 related signage in restrooms and common areas of the facility. LPA observed liquid hand soap and paper towels in restrooms. LPA reviewed temperature check logs for clients and staff members. It was noted that temperature records stopped being taken after April 2021. LPA secured a copy of the facility’s staff and client roster. LPA reviewed Covid-19 Mitigation Plan. LPA provided technical assistance regarding signage, visitation, training & training documentation, screening for visitors, and PPE.

No deficiencies were noted during the inspection.

An exit interview was conducted with S1 and a copy of this report was provided.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Norman Woodridge
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2021
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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