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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005729
Report Date: 07/12/2021
Date Signed: 07/12/2021 01:50:20 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:CARE AYESHAFACILITY NUMBER:
306005729
ADMINISTRATOR:DEL ROSARIO, LESTERFACILITY TYPE:
740
ADDRESS:452 S SWIDLER PLACETELEPHONE:
(657) 281-2103
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: 5DATE:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:Administrator Lester Del Rosario and Caregiver Angie HernandezTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted, granted entry into the facility by Staff and explained the reason for the visit.

During the visit LPA toured the facility with Caregiver Angie Hernandez. Administrator Lester Del Rosario arrived during visit. Facility is a 6 bedroom,( 5 resident bedrooms 1 staff bedroom) and 2 bathroom single story home. There are 5 Residents in care. LPA observed proper covid signage at front entrance of facility as well as sign in, sanitization and temperature check station. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring June 16, 2022. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper, and paper towels. Restrooms had proper hand washing signs posted. Residents were observed relaxing in the Living room watching TV and eating lunch. Facility has working smoke detectors, carbon monoxide detectors and audible alarms for each sliding door entrance/exit. Facility has 1 fire extinguisher which is fully charged. Facility has emergency food and water supply. Facility has ample supply of PPE. Facility has required Emergency Disaster Plan posted. Facility has a secured location for resident medication and files. LPA reviewed Clients files during visit. Clients emergency contact information and Physicians reports are current. Facility has designated visitation areas.

No deficiencies noted during todays visit. An exit interview was conducted with Administrator Lester Del Rosario and Caregiver Angie Hernandez. A copy of report was left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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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