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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005991
Report Date: 08/30/2022
Date Signed: 08/30/2022 12:17:59 PM


Document Has Been Signed on 08/30/2022 12:17 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:GARDEN GROVE GUEST HOME LLCFACILITY NUMBER:
306005991
ADMINISTRATOR:YVETTE LEMFACILITY TYPE:
740
ADDRESS:12882 SHACKELFORD LANETELEPHONE:
(714) 638-9470
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:47CENSUS: 32DATE:
08/30/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Yehuda Cohen TIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this case management visit for the purpose of a health and safety check. 32 residents currently reside at this location and hospice services are being provided to two (2) residents at this time. LPA arrived at facility was greeted at the door by caregiver and granted entry. Yehuda Cohen, Administrator arrived shortly after and met with LPA.

The facility stays at a comfortable temperature, the hot water temperature measured 113.3 Fahrenheit Degrees in resident restrooms. During the case management visit LPA took a tour of the inside of the facility, restrooms and common areas. LPA observed there was residents throughout the facility, there were residents having activities in the activities room, caregivers assisting residents throughout the facility, and a housekeeper cleaning the facility. LPA spoke with residents throughout the facility. LPA observed required department postings, covid-19 precautionary postings in the facility as well as hand washing signs throughout the facility. All restrooms observed to have ample supply of soap and appeared to be clean. LPA observed residents’ bedrooms and appeared to be clean and sanitary. All bedrooms observed to have all required components. LPA observed hallways and walkways were free of obstruction. There are no health and safety concerns observed in facility.

This report was reviewed with facility representative and a copy of this LIC809 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: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022
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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