306004679-4-12-2023-22-AS-LMAZ-CQU766-20230412212238

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004679
Report Date: 04/12/2023
Date Signed: 04/12/2023 09:23:05 PM

Document Has Been Signed on 04/12/2023 09:23 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 HOME		FACILITY NUMBER:	306004679
ADMINISTRATOR:	THEODORA FREDERICKSEN		FACILITY TYPE:	735
ADDRESS:	13361 NINA PLACE		TELEPHONE:	(949) 306-3566
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92843
CAPACITY: 6		CENSUS: 6	DATE:	04/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Theodora "Dora" Fredericksen		TIME COMPLETED:	03:30 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 Analysts (LPA) Lydia Martinez made an unannounced visit to conduct a Required – 1 Year inspection. Upon arrival LPA was greeted by facility Staff Jenelita Chua and Jiyasmin Coruna and was granted entry. LPA began inspection with introduction and visit purpose. There are currently 6 Clients residing at the facility. Six clients and two staff were present during today's visit. Clients appeared happy and well cared for. Administrator Theodora "Dora" Fredericksen arrived shortly after. LPA Martinez, along with Staff conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, den, garage and observed the following: Facility is a single-story house with 4 individual bedrooms, 1 shared bedroom, 1 staff bedroom, 5 bathrooms with a detached 2 car garage that is used for storage. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. LPA observed a table and chairs in back porch area for clients and visitors. Client bedrooms were observed to be spacious and easily accommodate furnishings such as lamps, chair, dresser and a bed. Bathrooms were observed to be clean, have a supply of soap and paper towels. Hot water temperature was within regulatory requirements. Linen and hygiene supplies were stocked. Emergency Phone Numbers and Exit Plan were reviewed. Food prep area is clean and organized. Food supply meets the requirement of one (1) week supply of non-perishable and two (2) day supply of perishables. Smoke detectors and carbon monoxide detectors were found to be operational. Fire Extinguishers were charged and mounted and were last serviced on 07/21/2022. LPA reviewed facility's Emergency Disaster/Fire drill log that shows last fire drill was on 02/21/2023. Stove burners, microwave, washer, and dryer are operational. Chemicals and sharps are made inaccessible to the clients. Laundry is done in the laundry room. Medications are centrally stored in a locked cabinet in the den. Medications reviewed appear to have been dispensed accurately. (see LIC809C)

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

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: 04/12/2023

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LPA Martinez 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.

First-Aid Kit had all the required elements. There is a land line in the facility.

LPA reviewed three client files and two staff files. LPA interviewed 6 clients and 2 staff. The clients P&I records were reviewed, LPA observed that an individual log is maintained for each client. All monies are accounted for and logs were kept to date.

Indoor and outside passageways are free of obstruction.

In order to update CCL file, please provide the following updated documents to CCL by 04/25/2023: 1.) Designation of Administrative Responsibility (LIC308) 2.) Personnel Report (LIC500); 3.) Emergency Disaster Plan (LIC610D); 4.) Surety Bond; and 5.) Administrator certificate.

Based on observations made during today's visit in the areas reviewed, there are no deficiencies being cited per Title 22, Division 6 of The California Code of Regulations. Copy of this report will be sent to email on file.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC809 (FAS) - (06/04)

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