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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 10:11:48 AM

Document Has Been Signed on 10/20/2022 10:11 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:POCUNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Staff on Duty - Edgar SacdalanTIME COMPLETED:
10:25 AM
NARRATIVE
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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies for complaint: 22-AS-20220714110042.

Citations issued on in LIC9099-D for 10/11/22 and LIC form 809-D on 10/20/22.

LPA De Perio met with 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 report.

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.

On 10/11/22, based on observation, and interviews, facility provided client with a 30-day notice, however did not meet regulations as specified in 85068.5(a)(1-5). This poses a potential threat on safety of clients in care.This poses an immediate health, safety or personal rights risk to persons in care.

*Deficiency cited under Title 22 Regulation 8506.8(a)(1-5) pertaining to Eviction Procedures has been CLEARED. On 10/18/22, AD provided POC to LPA De Perio via email of the review and understanding that about regulation and that if a client is given a 30-day notice, it will meet criteria as specified in 85068.5(a)(1-5). Licensee has complied with the terms of the POC.

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 306005504
VISIT DATE: 10/20/2022
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On 10/11/22, 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.

*Deficiency cited under Title 22 Regulation 8506.8(e) pertaining to Eviction Procedures has been CLEARED. On 10/18/22, AD provided POC to LPA De Perio via email of the review and understanding about regulation of needing to inform CCL if a client is provided with a 30-day notice. Licensee has complied with the terms of the POC.


LPA De Perio conducted an exit interview with S1 a copy of this report, and the cleared POC letter was 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
LIC809 (FAS) - (06/04)
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