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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004746
Report Date: 10/28/2021
Date Signed: 10/28/2021 11:30:26 AM

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:ALLEN'S PALM COVE RESIDENCE CAREFACILITY NUMBER:
306004746
ADMINISTRATOR:PETER NORAFACILITY TYPE:
740
ADDRESS:630 WEST STREETTELEPHONE:
(714) 310-9495
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:6CENSUS: 6DATE:
10/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Peter Nora, Euphrosyne DimaanoTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA explained the reason for the visit. The Administrator/Licensees Euphrosyne Dimaano and Peter Nora, arrived at 10:30 am. LPA observed all staff were wearing masks. LPA and Administrators/Licensees toured the facility. Facility has 6 bedrooms and 4 bathrooms and an attached 3 car garage that is used for storage. LPA observed all the bedrooms had the required furnishings. LPA observed 2 day perishable and 7 day non-perishable food supply on hand. LPA observed the fire extinguisher in the kitchen is fully charged. The garage is kept secured and is used for storage. LPA toured the backyard. There is a patio with a seating area. No bodies of water observed. No obstacles or hazards observed in the backyard. The back yard exit gate is operational. LPA inspected the first aid kit. The first aid kit had all the required elements. Smoke detectors/carbon monoxide detectors tested operational. Facility mitigation plan has been approved. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
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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