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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004679
Report Date: 05/24/2022
Date Signed: 05/24/2022 01:01:18 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/24/2022 01:01 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:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:26 AM
MET WITH:Jiyasmine Coruna, Direct Service Professional (DSP) and Theodora Fredericksen, AdministratorTIME COMPLETED:
01:00 PM
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 On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required Annual Inspection. LPA Quiroz was greeted, COVID-19 screened and granted entry into the facility by Direct Service Professional (DSP) Jiyasmine Coruna. Facility is a Level 4 Facility. LPA Rosie Quiroz explained the nature of the visit. (DSP) Jiyasmine Coruna indicated all incoming visitors are COVID-19 screened prior to entering the facility. Administrator Theodora Fredericksen arrived during today's visit. Adminsitrator Theodora Fredericksen has an Administrator's certificate with an expiration date of November 4, 2023.
On or about 11:37am, LPA Quiroz along with (DSP) Jenelita Chua began the tour of the inside and outside of the facility. There are six clients in care and there are no active COVID-19 cases in the facility. LPA Quiroz observed six of six clients in living room area and back porch area engaging with staff working on word searches and coloring. Six of six clients present at the facility during today's visit appeared to be clean and well taken care of. LPA Quiroz observed a COVID-19 check in station in the entry of the facility; LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility. During today's visit, LPA Quiroz interviewed 6 of 6 clients.
On or about 12:15pm, LPA Rosie Quiroz reviewed 6 of 6 clients records. All restrooms observed to have a supply of soap, appeared to be clean and water temperatures were recorded to be within required limits. LPA Quiroz inspected client’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in staff room and garage area readily available for staff and clients. LPA Quiroz toured the outside of the facility and observed table and chairs in back yard/back porch area for clients and visitor's enjoyment.

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SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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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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: DORA'S GUEST HOME
FACILITY NUMBER: 306004679
VISIT DATE: 05/24/2022
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The facility has completed the LIC 808 Mitigation Plan. The LIC 808 plan was received by the Department on January 20, 2021. The LIC 808 Mitigation Plan was approved on September 20, 2021. LPA Quiroz was informed that "all clients and staff have had their COVID-19 vaccinations and first booster. Facility is recording client's temperatures daily, two times per day.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

During today's visit, LPA Quiroz provided Consultation on Title 22 and COVID-19 Infection Control throughout today's visit.

This report was reviewed with (DSP) Jiyasmine Coruna and (AD) Theodora Fredericksen and a copy of this report and LIC 811 Confidential Names were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC809 (FAS) - (06/04)
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