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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004806
Report Date: 12/07/2021
Date Signed: 12/29/2021 05:51:58 PM

Document Has Been Signed on 12/29/2021 05:51 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:RICHLAND GUEST HOMEFACILITY NUMBER:
306004806
ADMINISTRATOR:RAQUEL VALDIVIA GONZALEZFACILITY TYPE:
735
ADDRESS:1031 W. RICHLAND AVENUETELEPHONE:
(714) 547-1053
CITY:SANTA ANASTATE: CAZIP CODE:
92703
CAPACITY: 18CENSUS: 16DATE:
12/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Administrator Raquel GonzalezTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit to Richland Guest Home. The purpose of today’s visit was to conduct the 1 Year Required visit. LPA was allowed entry into the facility and met with Administrator Raquel Gonzalez. Administrator certificate expiring on 02/21/2022. Facility is licensed for 18 ambulatory clients. Facility consists of four single story bungalows. One bungalow has 2 separate living quarters which are three bedrooms and two bathrooms in each living quarter. One bungalow (main bungalow) is a four bedroom two bathroom structure and the last bungalow is an office/storage structure. One of the bungalows is a room and board. The bungalows are separated by gender.

LPA Frank toured the facility. Sixteen resident residing in the facility and no active COVID-19 cases. All


resident and staff are vaccinated also, has a booster LPA observed 16 resident on site and appeared clean and well taken care of. LPA observed required department postings in the facility as well as hand washing signs in the
restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Residents bedrooms
appeared clean and sanitary and had all required components. LPA Frank tested the hot water temperature,
which measured 110 degrees F in resident bathroom. Resident areas were noted to be a comfortable temperature. LPA observed the emergency disaster and evacuation plans. Adequate supply of 7-day non-perishable and 2-day perishables are stored in the kitchen and pantry. Facility has back-up emergency food and water supply as well as PPE supplies. Facility has completed the LIC 808 Mitigation Plan.
The facility is conducting COVID-19 testing as required by the latest guidance.
No citations noted during today's visit. Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2021
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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