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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005733
Report Date: 09/01/2022
Date Signed: 09/01/2022 03:50:21 PM


Document Has Been Signed on 09/01/2022 03:50 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:AVALON GUEST MANOR IFACILITY NUMBER:
306005733
ADMINISTRATOR:SHARIFI, MARYAM FARINAZFACILITY TYPE:
740
ADDRESS:1857 SHEDDON STTELEPHONE:
(714) 869-3532
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:6CENSUS: 5DATE:
09/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Care staff Sina Sharifi TIME COMPLETED:
01:36 PM
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Licensing Program Analyst (LPA) conducted an unannounced visit for the purpose of conducting a Required 1 Year inspection. LPA Frank was greeted and granted entry by staff Sina Sharifi and reason for the visit was explained.

LPA tour the facility with Administrator Sina Sharifi. Licensee Maryam Shrifi arrived at the letter time. There are 5 residents residing in the facility and no active COVID-19 cases. LPA observed 5 residents on site appeared clean and well taken care and 2 resident are receiving hospices care. LPA observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Resident bedrooms appeared clean and sanitary. LPA observed 2 day supply of perishables and 7 day supply of non-perishable food is available for the number of residents present. Hygiene supplies and supply of linen were observed in quantities for the number of residents in care. LPA observed locked areas for toxins and hazardous items. Medication were observed locked in cabinet. LPA observed Facility’s physical plant, hallways appears to be clean and free of debris, free of odor. Sufficient lighting observed throughout the facility. No bodies of water, weapons or ammunition on premises. In addition, LPA Frank tested the hot water temperature, which measured 107.8 degrees F in resident bathroom. Resident areas were noted to be a comfortable temperature. Smoke detectors and carbon monoxide detector were tested and are operational. Fire extinguishers were fully charged. Fire drill was conducted on 7/30/22. Facility stove, oven, microwave, refrigerator, washer and dryer are clean and operational. LPA observe the facility to be clean and in good repair. LPA Frank reviewed Emergency Disaster Plan (LIC610E); LIC 9020A Client Roster; LIC 808) Mitigation Plan and Current Liability Insurance; Designation of Administrative Responsibility (LIC308) and Personnel Report (LIC500), Infection Control Plan.

Based on the observations made during today’s visit, no deficiencies are being cited in area inspected. This report was discussed with the facility representative and a copy was provided.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Shobhana FrankTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
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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