306005195-7-20-2023-22-AS-CGUZ-CTWU9S-20230720152339

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005195
Report Date: 07/20/2023
Date Signed: 07/20/2023 03:23:42 PM

Document Has Been Signed on 07/20/2023 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:	EMBASSY RESIDENTIAL CARE II		FACILITY NUMBER:	306005195
ADMINISTRATOR:	KON, CORA		FACILITY TYPE:	735
ADDRESS:	1621 E SANTA ANA STREET		TELEPHONE:	(714) 732-7217
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92805
CAPACITY: 6		CENSUS: 5	DATE:	07/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Gloria Aviles		TIME COMPLETED:	03:40 PM

NARRATIVE

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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. Upon arriving, LPA rang the doorbell and knocked on the door several times. After receiving no response, LPA walked the perimeter of the facility and did not observe anyone on the premises. At 12:21 p.m. LPA placed a call to Administrator (AD) Cora Kon. Per AD, all clients were away at day program and staff had gone out to lunch. At 1:00 p.m. Staff Gloria Aviles and Staff Leonardo Aviles arrived at the facility and the purpose of the inspection was discussed.

During the inspection LPA and Staff conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a one-story house with three client bedrooms, two bathrooms, and two staff bedrooms. All client bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. The back yard has a shaded sitting area. LPA observed two staff, and clients were not present initially. Two clients arrived from day program at 2:15 p.m. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 116.2 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted in the dining room area of the facility. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Stove burners, microwave, washer, and dryer were all inspected. Sharps were observed to be locked a kitchen cabinet. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication cabinet was observed to be locked and lock is operational. The first aid kit has all the required elements. LPA reviewed five client files and three staff files. LPA interviewed two clients present and the two staff present.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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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