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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005422
Report Date: 07/26/2023
Date Signed: 07/26/2023 02:29:48 PM


Document Has Been Signed on 07/26/2023 02:29 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:COUNTRY GARDEN GUEST HOMEFACILITY NUMBER:
306005422
ADMINISTRATOR:BALDAZO, RIALYNFACILITY TYPE:
740
ADDRESS:13352 GARDEN GROVE BLVDTELEPHONE:
(714) 458-2324
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY:6CENSUS: 6DATE:
07/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Rialyn BaldazoTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Staff Alex Baldazo. LPA met with Administrator (AD) Rialyn Baldazo and discussed the purpose of the inspection

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

This is a one-story home with three resident bedrooms, three bathrooms, and one staff bedroom. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. The back yard and front yard have a shaded sitting area. LPA observed two staff and 6 residents present. Residents were observed in the living room, watching music videos and engaging in physical exercise. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 107.4 F degrees.

LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted in the dining 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 locked in a kitchen drawer. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents. Medication cabinet was observed to be locked and lock is operational. LPA reviewed six resident files and three staff files. LPA interviewed four residents and two staff.

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.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
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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