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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005778
Report Date: 01/21/2021
Date Signed: 01/22/2021 08:32:52 AM

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:ANNISSA GEM CAREFACILITY NUMBER:
306005778
ADMINISTRATOR:LIMPIADO, GIDEONFACILITY TYPE:
740
ADDRESS:825 LILAC DRIVETELEPHONE:
(714) 203-1702
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 6DATE:
01/21/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Gideon LimpiadoTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Michelle Reed contacted the facility via telephone to commence an announced Pre-licensing visit due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call with Gideon Limpiado. Caregivers Tony DeGuzman and Debbie Mejia were also present. Gideon Limpiado will be the designated Administrator for the facility.
A Change of Ownership application to operate an Residential Care Facility for the Elderly was submitted to the Central Applications Unit (CAU) on 1/27/2020 for a capacity of 6 non-ambulatory residents. The Placentia Fire and Life Safety Department conducted a Fire Safety Inspection on 1/13/21 and granted a fire clearance. A virtual tour of the physical plant was conducted inside and out at approximately 2:15pm with Limpiado Gideon and the following was observed:
Structure:
Facility is a one story house with 6 bedrooms and 2 full baths and 1 1/2 bath. 5 bedrooms and 2 bathrooms are designated for residents and 1 bedroom and 1 bathroom are for staff. There is also a living room, dining area and kitchen. The backyard has a table and chairs and shade.
Signal System:
Central air/heating system installed with a central panel to control entire house.
Bedrooms Residents:
The resident bedrooms accommodate residents' furnishings and meet Title 22 regulation at this time.
Bathrooms:
Bathrooms have working toilets, sinks and showers. Grab bars and non-slip mats were present.
Linens and Hygiene Supplies:
Adequate supply of linens was observed
Ombudsman Poster, Personal Rights and See Something Say Something Poster
Ombudsman poster was posted at the time of visit as well as the See Something, Say Something Poster for Complaints. Personal rights and the License was also present
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ANNISSA GEM CARE
FACILITY NUMBER: 306005778
VISIT DATE: 01/21/2021
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Food Service:
Adequate supply of 7-day non-perishable and 2 day perishables are stored in the kitchen and pantry and will include fruits and vegetables.
Smoke and Carbon Monoxide Detectors:
Smoke detectors and carbon monoxide systems were observed working at the time of this visit
Fire Extinguishers:
The fire extinguisher was mounted and fully charged at the time of this visit
Appliances:
Refrigerator/freezer and microwave which were clean and noted to be operational. Washer and dryer were clean and noted to be operational.
Toxins:
Will be locked and inaccessible to residents
Water Temperature:
Tested and met Title 22 regulation at the time of visit, between 105 and 120 degrees F. 112 degrees F.
Medications, First Aid Kit & Manual:
First Aid kit present and stored resident medications. Medication will be stored and locked in the facility living area.
Resident and Staff Files:
Records observed to be locked for privacy
Component III
Component III was conducted

The Prelicensing is complete. No corrections are needed.

The Licensee will be granted upon a final review by the Central Applications Bureau and approval by management.

An exit interview was conducted with Gideon Limpiado and a copy of this report was emailed for signature.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021
LIC809 (FAS) - (06/04)
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