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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005778
Report Date: 02/17/2022
Date Signed: 02/17/2022 01:29:28 PM


Document Has Been Signed on 02/17/2022 01:29 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: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:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Karmian CalangiTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required inspection visit. LPA was greeted at the door by caregiver and granted entry. LPA advised caregiver the reason for the visit. Karmian Calangi, Administrator arrived shortly after and met with LPA.
LPA began the tour of the inside and outside of the facility accompanied by caregiver. The facility currently has 6 residents in care. LPA observed one resident in the living room and remainder of the residents in their bedrooms. All residents appeared to be happy and well taken care of. Facility appears clean and sanitary. Facility staff screens all visitors to the facility and LPA observed a screening station in the entrance of the facility. Facility keeps documentation in regard to covid for all the staff, visitor and residents. LPA observed facility has covid precautionary postings throughout the facility as well as required department postings. Facility has an active covid prevention plan in place for the safety of the resident in care. LPA observed a supply of emergency food and water stored in the attached garage. It was observed that facility has supply of PPE, incontinence and cleaning supplies. Facility has sanitation precaution in place through out the facility and all common spaces. LPA toured the outside of the facility and observed a shaded seating area for residents, area is used for outdoor visitation as well. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation as needed. Facility bedrooms are one shared bedroom and four private bedrooms. LPA was advised staff and residents are in the process of completing their covid booster shot. The facility has completed the LIC808 Mitigation plan, LPA reviewed and approved the plan on today’s visit.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with facility representative and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
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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