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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005821
Report Date: 06/15/2021
Date Signed: 06/16/2021 07:14:36 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:PARADISE GARDEN GUEST HOMEFACILITY NUMBER:
306005821
ADMINISTRATOR:AZNAR, MARY GRACEFACILITY TYPE:
740
ADDRESS:13392 GARDEN GROVE BLVDTELEPHONE:
(714) 591-5850
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY:6CENSUS: 5DATE:
06/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Mylene Baldazo and Tessie DamicogTIME COMPLETED:
11:54 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Manager Mylene Baldazo and explained the reason for the visit. Administrator Tessie Damicog was present as well.

At 10:30 AM, LPA toured the facility with Administrator Damicog and Manager Mylene Baldazo. Facility has 5 residents in care during today's visit. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All residents rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Restrooms have hand washing signage posted. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the entrance of the facility. Facility utilizes a visitor sign in sheet. Facility takes resident temperatures daily and documents results. Facility has covid precaution postings as well as all required department postings. Administrator Damicog has an administrator certificate expiring on 06/26/2022. Facility has completed the mitigation plan and LPA observed the emergency disaster plan posted in facility as well. LPA observed adequate emergency food and water as well as the first aid kit. LPA toured the outside grounds and observed ample shaded outside visitation area. LPA observed a back house where administrator resides. Exit gates are unlocked. Facility conducts activities outside in the backyard. LPA observed the locked medication storage area. Facility has ample supply of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. All staff and residents are vaccinated for Covid-19.

LPA consulted with Administrator regarding the importance of following all department recommended visitation guidelines.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
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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