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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004497
Report Date: 01/04/2024
Date Signed: 01/04/2024 02:59:42 PM

Document Has Been Signed on 01/04/2024 02:59 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: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:
01/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Wilhelmina BayonaTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Staff Wilhelmina Bayona and explained the purpose of the inspection. During the inspection, LPA and Staff Bayona conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a single-story house with three client bedrooms, two bathrooms, one staff bedroom, and one tenant bedroom. Facility currently has six clients in care and two tenants. Both tenants have been fingerprinted and background cleared. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. The backyard has a shaded sitting area. LPA observed one staff and one client present, as all other clients were away at day program, working, or at the gym. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 120.4 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with service tag indicating it was last serviced on 3/28/23. Gas stove, microwave, washer, and dryer were all inspected and tested operational. Sharps, all and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication is stored in a locked dresser located in the staff bedroom. LPA reviewed six client files and observed three of six files had Needs and Services Plans dated 9/15/2020. Staff was unable to provide LPA with a recent Needs and Services Plan for three out of three clients; a Deficiency was cited on today’s date. LPA reviewed two staff files and observed an Administrator (AD) certificate with an expiration date of 4/29/21. AD was contacted by phone and admitted they have yet to renew certificate; a Deficiency was cited on today’s date. LPA interviewed staff and clients present.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
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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Document Has Been Signed on 01/04/2024 02:59 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 01/04/2024 at 01:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ALENA'S GUEST HOME
FACILITY NUMBER: 306004497

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on AD admission, the licensee did not comply with the section cited above as AD is not currently certified which poses a potential health and personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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AD stated they would renew their certificate immediately and provide LPA with proof of documentation submitted for certificate renewal via email by POC date.
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three out of six client files. LPA observed files had Needs and Services Plans dated 9/15/2020. Staff was unable to provide LPA with a recent Needs and Services Plans for the three clients which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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AD stated they would update Needs and Services Plans for all three clients and provide LPA with a copy via email by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 306004497
VISIT DATE: 01/04/2024
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Based on the observations made during today’s inspection, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
LIC809 (FAS) - (06/04)
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