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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005987
Report Date: 04/08/2026
Date Signed: 04/08/2026 12:48:45 PM

Document Has Been Signed on 04/08/2026 12:48 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ATLANTA HOUSEFACILITY NUMBER:
306005987
ADMINISTRATOR/
DIRECTOR:		LOPEZ, ANICIAFACILITY TYPE:
735
ADDRESS:2204 S ATLANTA STTELEPHONE:
(714) 539-0696
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: 6DATE:
04/08/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:09 AM
MET WITH:Early Maglaya TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On today's date Licensing Program Analyst (LPA) William Vanegas made an unannounced visit for the purposes for completing an annual inspection. Upon arrival LPA was greeted and granted entry to the facility by facility staff. LPA explained the purposes of the visit and Leas Staff (LS) Early Maglaya was notified via telephone. LS arrived shortly after to assist with the annual inspection. LPA began a tour of the facility and observed the following.

The facility is a one storied home with four bedrooms, all bedrooms are utilized for clients in care. The facility has two restrooms which are used for clients in care,staff and visitors. There is an attached two car garage as well. LPA observed kitchen area to be clean and free of any debris and mildew. LPA observed kitchen area to have a microwave, a refrigerator, a gas stove, and a dishwasher. All appeared to be in good repair and tested operational. LPA observed there to be a two day supply of perishable food and a seven day supply of non-perishable food as well as a sufficient amount of emergency water.

LPA observed all client rooms to have all required furnishings such as a bed, clean linens in good repair; meaning no strains or tares, a reading lamp, a chair, a chest of drawers, and enough storage space to store personal belongings. LPA observed all restrooms to be clean and free of any toxins, mildew, and debris. LPA observed restrooms to have all required furnishings such as slip resistant floor matts, grab bars, and a shower chair. LPA observed all toilets and faucets to be operational. Hot water temperature tested between 112.3 and 116.5 degrees Fahrenheit.
CONTINUED ON LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ATLANTA HOUSE
FACILITY NUMBER: 306005987
VISIT DATE: 04/08/2026
NARRATIVE
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LPA observed all fire extinguishers to be fully charged and inspected recently. LPA observed all smoke detectors and carbon monoxide detectors to be in good repair and tested operational. LPA observed first aid kit to have all required items such as adhesive tape, scissors, tweezers, bandages, a thermometer and a first aid manual.

LPA toured the outside of the facility and observed the following: The back yard is large enough to participate in outdoor activities upon resident request. LPA observed there to be an outdoor shaded sitting area. LPA observed no obstructions or toxins along side exits. LPA observed side gates to be unlocked and self latching.

LPA reviewed six client files and two staff files, one staff file was not available for review and a deficiency was issued on today's date. One resident file was unavailable for review and a deficiency was issued on today's date. Annual training was completed and documented correctly. LPA reviewed P&I with facility staff all balances were documented correctly and cash on hand was accurate. LPA reviewed medications with facility staff per LPA review all medications are being administered per physicians orders and are being documented correctly.

Based on observations made during today's inspection deficiencies will be issued per title 22 chapter 8 division 6 of the California Code of Regulations. An exit interview was conducted with facility staff and a copy of this report and appeal right were provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/08/2026 12:48 PM - It Cannot Be Edited


Created By: William Vanegas On 04/08/2026 at 12:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ATLANTA HOUSE
FACILITY NUMBER: 306005987

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 2 staff records not being available for review which poses/posed a potential safety risk to persons in care.
POC Due Date: 04/22/2026
Plan of Correction
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Administrator Will send LPA staff file for review before P.O.C due date via email.
Type B
Section Cited
CCR
80068(a)(2)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any. (2) The licensee shall maintain a copy of the certification in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in 1 out of 6 resident files not being available for reveiw. Which poses/posed a potential health and safety or personal rights risk to persons in care.
POC Due Date: 04/22/2026
Plan of Correction
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Administrator will send resident file via email for LPA review by P.O.C due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM MANAGER:
William Vanegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2026


LIC809 (FAS) - (06/04)
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