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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005836
Report Date: 04/18/2022
Date Signed: 04/18/2022 10:27:48 AM


Document Has Been Signed on 04/18/2022 10:27 AM - 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:CASA DOLCE HOMEFACILITY NUMBER:
306005836
ADMINISTRATOR:EMIGH, JEANINEFACILITY TYPE:
740
ADDRESS:1601 SKYLINE DRIVETELEPHONE:
(714) 213-8423
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:6CENSUS: 3DATE:
04/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Jeanine EmighTIME COMPLETED:
10:40 AM
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Licensing Program Analysts (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted by staff Maria Huaracha and granted entry into the facility. LPA Gutierrez discussed the purpose of the inspection. During the inspection LPA Gutierrez and staff Huaracha conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following:

This is a single-story house with four bedrooms, and three bathrooms. During the inspection LPA observed one staff and three residents in care. Residents were observed resting in their respective rooms. LPA observed no hand washing signs in any of the bathrooms and the facility does not have a 30-day supply of PPE on hand; two Technical Advisories were given on this date. LPA inspected common areas, resident rooms, kitchen, and garage and observed the garage is currently under construction. LPA observed hallways and walkways were free of obstruction.

LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, infection control training, PPE, staffing and staffing shortages.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Jeanine Emigh who arrived at 9:57am, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022
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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