<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004679
Report Date: 09/22/2021
Date Signed: 09/22/2021 03:23:23 PM

Document Has Been Signed on 09/22/2021 03:23 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:DORA'S GUEST HOMEFACILITY NUMBER:
306004679
ADMINISTRATOR:THEODORA FREDERICKSENFACILITY TYPE:
735
ADDRESS:13361 NINA PLACETELEPHONE:
(949) 306-3566
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY: 6CENSUS: 6DATE:
09/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Dora Fredericksen and Jiyasmin CorunaTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Dora Fredericksen arrived during the visit. Administrator Fredericksen has a current administrator certificate expiring on 11/04/2021.

At 10:22 AM, LPA toured the facility with Caregiver Jiyasmin Coruna. Facility has 6 clients in care during today's visit. LPA observed clients relaxing in the facility. All clients appeared happy, well taken care of, and engaged with LPA. Facility appears clean and sanitary. All client rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Four rooms are single occupancy and one is double occupancy. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the facility. Facility utilizes a visitor sign in sheet. Facility takes client and staff temperatures daily and documents. Facility has covid precaution postings as well as department postings. LPA observed the first aid kit has all required items. Facility mitigation plan has been approved. LPA observed an ample supply of emergency food and water. LPA toured the outside grounds and observed the outside visitation area. Exit gate is unlocked and self latching. LPA observed the locked medication storage area. Facility has a plan for covid testing clients and staff as needed as well as a plan for isolation and quarantine. LPA reviewed six client files during the visit and all files are up to date including emergency information. All clients and staff are vaccinated for Covid-19.
LPA consulted with Administrator regarding the importance of documenting all visitor temperatures upon entry into the facility.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1