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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005680
Report Date: 04/01/2021
Date Signed: 04/01/2021 03:50:02 PM

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:CARNELIAN VILLASFACILITY NUMBER:
306005680
ADMINISTRATOR:STRUVE, JINGFACILITY TYPE:
740
ADDRESS:1773 S. CARNELIAN STREETTELEPHONE:
(714) 860-4490
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY:6CENSUS: 6DATE:
04/01/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Administrator Cherie WoodTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Sean Haddad conducted an unannounced Case Management tele-visit for the purpose of a health and safety check via FaceTime due to COVID-19 Pandemic and precautionary measures. LPA explained the reason for today's visit and conducted a virtual tour of the inside of the facility, common areas, and kitchen along with Administrator (AD) Cherie Wood and observed the following:

LPA observed there were 2 staff present, all wearing PPE. LPA observed 6 residents present, with 3 residents in the living room. LPA interviewed all 6 residents, confirmed they were doing well, and observed no health and safety issues. LPA inspected common areas and kitchen, observed they were clean and organized, and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed hallways and walkways were free of obstruction.

LPA requested incident reports, care logs, staff files, relevant communications, and resident files for further review.

There were no health and safety concerns observed in the areas inspected. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 of the California Code of Regulations.

An exit interview was conducted with AD. This report will be emailed and an electronic email read receipt confirms receipt of the report. AD agrees to sign the report and email it back to LPA.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021
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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