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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004502
Report Date: 04/06/2022
Date Signed: 04/07/2022 09:16:49 AM

Document Has Been Signed on 04/07/2022 09:16 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:L & D BOARD AND CAREFACILITY NUMBER:
306004502
ADMINISTRATOR:LILIA DUELASFACILITY TYPE:
735
ADDRESS:10361 16TH STREETTELEPHONE:
(714) 867-6028
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY: 6CENSUS: 3DATE:
04/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:49 PM
MET WITH:Caregiver Angie Austria / Adminstrator Delfin DuelasTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Andrea Mendivil and Claudia Gutierrez and Licensing Program Managers (LPMs) Alisa Ortiz and Armando Lucero conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPAs and LPMs were greeted and granted entry into the facility by Caregiver Angie Austria and explained the reason for the visit. Administrator Delfin Duelas arrived during the tour at 2:20pm.

At 1:50pm, LPAs and LPMs toured the facility with Caregiver, Angie Austria .The facility is a single story home with 6 bedrooms and 2 bathrooms. Facility has 2 clients present during today's visit. LPAs and LPMs observed clients relaxing in their respective rooms. Facility appears clean and sanitary. All client rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Cameras were observed in living room and kitchen, Administrator Delfin Duelas indicated they were non-operational.
LPAs and LPMs observed the screening/ sanitizing station in the entrance of the facility. Facility takes client and staff temperatures daily and documents. Facility has COVID precaution postings as well as all required department postings. The facility mitigation plan has been completed and approved.

LPAs and LPMs observed 3 day emergency food and water. LPAs and LPMs observed locked medication drawer. LPAs and LPMs toured the outside grounds and observed multiple outside shaded visitation areas. Facility has a plan for covid testing clients and staff as needed as well as a plan for isolation.
LPA Mendivil observed a 4 week supply of PPE. All staff and clients are vaccinated for Covid-19.
LPA Mendivil reviewed all client files and all contained required documentation including updated emergency information.

No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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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