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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005195
Report Date: 08/09/2024
Date Signed: 08/09/2024 10:01:28 AM

Document Has Been Signed on 08/09/2024 10:01 AM - 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 IIFACILITY NUMBER:
306005195
ADMINISTRATOR/
DIRECTOR:
KON, CORAFACILITY TYPE:
735
ADDRESS:1621 E SANTA ANA STREETTELEPHONE:
(714) 732-7217
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 6CENSUS: 6DATE:
08/09/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Gloria AvilesTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced collateral visit for the facility at Harbor Inn & Suites, 12792 Palm St, Garden Grove, CA 92840. LPA met with Staff Gloria Aviles and explained the reason for the visit. At the time of the visit all clients were observed leaving for day program.

On August 7, 2024, Administrator (AD) Cora Kon reported to the Department clients had been relocated to current location on August 6, 2024, due to renovations taking place at the facility.

During today’s visit, LPA conducted checks on the welfare of the clients. No immediate health and safety concerns were observed. Six of six clients are currently staying at this location and are occupying a total of three rooms. Each room has two beds and one bathroom, and each client has their own bed. There is a fourth room being occupied by staff. Client medication and files were observed to be locked in the staff room.

At 9:00 a.m., AD was contacted by phone and stated renovations at the facility are due to be completed on Monday August 12, 2024. Per AD, renovations consist of remodeling the kitchen and bathroom, including kitchen cabinets, counter tops, appliances, bathroom tub, and flooring being replaced. AD stated permits do not need to be obtained as no walls are being taken down and no room additions are being made. AD to submit a letter entailing who is doing the renovations and the scope of work that is being done by close of business today. AD stated they will submit a written report within seven days as required by regulation.

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 provided at the end of the inspection.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2024
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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