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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005504
Report Date: 01/25/2023
Date Signed: 01/25/2023 02:59:30 PM

Document Has Been Signed on 01/25/2023 02:59 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
ORANGE & INLAND A/SC, 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: 4DATE:
01/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Cresencia SantiagoTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to the facility to conduct a required inspection visit. LPA arrived at facility was greeted and granted entry by Crescencia Santiago, Administrator. LPA met with Administrator and explained the nature of the visit.

LPA began the tour of the facility. Upon entry LPA observed two clients and Administrator with regional center having a meeting. There are four clients’ in care and there are no active covid-19 cases in facility. LPA observed covid precautionary posting and required department postings throughout the facility. There is a check in station in the main entry of the facility with a sign in sheet, temperature checks, PPE supply and sanitizer. Restrooms observed to have required supplies. LPA inspected client’s bedrooms and appeared to be clean and sanitary. All bedrooms observed to have all required components. Client bedrooms are all private bedrooms with one resident per. There is at least a 30 day supply of PPE stored in hallway storage. LPA observed an outside visitation area with ample shading. Licensee has required Mitigation plan and Emergency Disaster Plan in place. Facility has emergency food and water supply. Facility has a secured medication cabinet for Client medication and files are kept in locked hallway closet.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the facility representative and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2023
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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