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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005504
Report Date: 10/20/2022
Date Signed: 10/20/2022 09:44:50 AM

Document Has Been Signed on 10/20/2022 09:44 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:OUR LADY OF GUADALUPE HOMEFACILITY NUMBER:
306005504
ADMINISTRATOR:CRESENCIA D. SANTIAGOFACILITY TYPE:
735
ADDRESS:24361 BRIDGER RDTELEPHONE:
(949) 328-9784
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 3DATE:
10/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Staff on duty - Edgar SacdalanTIME COMPLETED:
09:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Celine De Perio made an unannounced case management visit in conjunction with the complaint: 22-AS-20220714110042.

LPA De Perio was greeted and granted entry by staff on duty (S1) Edgar Sacdalan, who contacted facility administrator (AD) Cresencia "Christine" Santiago about visit. AD Santiago was unavailable to be present, however provided consent for S1 to receive and sign reports (LIC809, LIC9099, LIC9099-C, LIC9099-D dated for 10/11/22).

For this visit, there were a total of 3 clients in care, of which 1 was present at facility, 1 was at work, and 1 was attending Day Program.

In delivering the findings for the complaint on 10/11/22, the following concerns were found. LPA De Perio made consultation on California Code of Regulations Sections: 85068.5 Eviction Procedures

Upon conducting the investigation, it was stated that facility failed to inform Community Care Licensing with a notice of client's 30-day notice.

For the visit conducted on 10/11/22, citations were issued per Title 22 Division 6 of the California Code of Regulations, of which were given on 10/11/22 and 10/20/22 (via LIC809-D)

LPA De Perio conducted an exit interview with S1 a copy of this report, regulations discussed and specified on LIC9099-D and Appeal Rights were provided to the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022
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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Document Has Been Signed on 10/20/2022 09:44 AM - It Cannot Be Edited


Created By: Celine DePerio On 10/20/2022 at 09:25 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: OUR LADY OF GUADALUPE HOME
FACILITY NUMBER: 306005504

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2022
Section Cited
CCR
85068.5(e)

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85068.5 Eviction Procedures
(e) A written report of any eviction processed in accordance with (a) above shall be sent to the licensing agency within five days of the eviction.
This requirement is not met as evidence by:
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As a plan of correction (POC), facility will inform CCL if a client is provided with a 30-day notice.
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Based on observation, and interviews, facility failed to inform CCL about client's 30-day notice. This poses a potential threat on safety of clients in care.
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Facility will submit written proof to CCL and the assigned LPA adhering to this POC and understanding of the regulation discussed on or by 10/25/2022.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Luz Adams
LICENSING EVALUATOR NAME:Celine DePerio
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022


LIC809 (FAS) - (06/04)
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