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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005504
Report Date: 01/18/2024
Date Signed: 01/18/2024 01:40:50 PM

Document Has Been Signed on 01/18/2024 01:40 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 COUNTY ASC, 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:
01/18/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Cresencia Santiago - AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst, (LPA) Dwayne Mason Jr. arrived at the facility for the purpose of conducting a Plan of Corrections (POC) inspection. LPA was greeted and granted entry by Michelle Lobaton, Caregiver. LPA stated the purpose of the inspection. Administrator Cresencia Santiago joined the inspection approximately twenty minutes after LPA's arrival.

LPA observed clients to be away at Day Program or in their own rooms. LPA toured facility and observed the facility to be clean, sanitary and safe.

LPA reviewed Facility Drill Log. Based on record review, facility conducted a fire drill on 1/8/2024. LPA reviewed P&I with Administrator. P&I funds matched correctly with the ledger.

Based on today's inspection, the LPA determined that the facility has fulfilled the Plan of Corrections issued on 1/5/2024 by the assigned POC due date. An exit interview was conducted and a copy of this report was provided to the facility
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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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